GBA2 - Risk Adjustment

Question 1

Transfers funds from plans with lower risk enrollees to plans with higher risk enrollees

Answer 1

Risk Adjustment

Question 2

Provides payments to plans that enroll higher cost individuals

Answer 2

Reinsurance

Question 3

Limits losses & gains beyond allowable range

Answer 3

Risk Corridors

Question 4

Patient opts for value based facility & patient will have lower OOP costs

Answer 4

COE Pricing

Question 5

Limit share of premiums that goes towards admin expenses/profits vs being used to pay for HC claims

Answer 5

Medical Loss Ratio

Question 6

Negotiate lower prices in exchange for some assurance of patient volume (lower utilization at lower prices)

Answer 6

Selective Contracting

Question 7

Lower utilization, lower costs. Introduced Selective Contracting.

Answer 7

Managed Care Plan

Question 8

Insurer negotiates prices with providers but then sets limits/max on how much they will pay for procedure

Answer 8

Reference Pricing

Question 9

Amount we pay over expected loss (includes insurer’s admin costs, reserves, and profits)

Answer 9

Loading Fee

Question 10

ER’s make fixed contribution to each of the health plans they fofer

Answer 10

Level dollar premium contribution plan

Question 11

Management approach to long term success through customer satisfaction, where all members of org. participate in improving processes/products/services

Answer 11

Total Quality Management (TQM)