Quality Assurance & Compliance Flashcards
7 cards from real ACA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Assurance & Compliance flashcards as text
Under ACA Section 1557, discrimination based on which grounds is prohibited in health programs receiving federal financial assistance?
Answer: Race, color, national origin, sex, age, and disability
Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, and disability in federally funded health programs.
What is the ACA's requirement for health plans regarding coverage of preventive services rated 'A' or 'B' by the U.S. Preventive Services Task Force?
Answer: Plans must cover them without cost-sharing
Non-grandfathered plans must cover USPSTF Grade A and B preventive services with no cost-sharing for the enrollee.
Under the ACA, which entity conducts external review of denied health insurance claims when an internal appeal is unsuccessful?
Answer: An independent review organization (IRO)
The ACA mandates access to an IRO, a neutral third party, to conduct external review of adverse coverage decisions after internal appeals are exhausted.
A health plan's quality improvement activities counted toward MLR must relate to which of the following?
Answer: Activities that improve health care quality, such as disease management programs
MLR quality improvement activities must directly improve health care quality and patient safety, such as disease management, care coordination, or wellness programs.
Under ACA exchange regulations, what is the consequence for a QHP issuer that repeatedly fails to meet network adequacy standards?
Answer: Decertification from the exchange
Persistent failure to maintain adequate provider networks can result in CMS decertifying the QHP, removing it from the exchange marketplace.
What ACA requirement specifically addresses maternal and newborn hospital stays?
Answer: Plans cannot restrict coverage for a hospital stay to less than 48 hours following a vaginal delivery
Building on NMHPA, ACA plans may not restrict a hospital stay following vaginal delivery to less than 48 hours or a cesarean section to less than 96 hours.
Under the ACA's provider nondiscrimination provision, what are plans prohibited from doing?
Answer: Discriminating against any health care provider acting within the scope of their license
ACA Section 2706 prohibits health plans from discriminating against providers who are acting within the scope of their state-issued license or certification.