Congress enacted three clauses relating to the preemptive effect of the Employee Retirement Income Security Act of 1974 (ERISA). One of these clauses preserves from ERISA preemption any state law that regulates insurance, banking, or securities, with the exception of the exemption for self-funded employee benefit plans. This clause is called the

A. Savings clause

B. Preemption clause

C. Deemer clause

D. De novo clause

In 1994, the Department of Justice (DOJ) and the Federal Trade Commission (FTC) revised their 1993 healthcare-specific antitrust guidelines to include analytical principles relating to multiprovider networks. Under the new guidelines, the regulatory agencies will use the rule ofreason to analyze joint pricing activities by competitors in physician or multiprovider networks only if

A. Provider integration under the network is likely to produce significant efficiencies that benefit consumers

B. The providers in a network share substantial financial risk

C. The combining of providers into a joint venture enables the providers to offer a new product

D. All of the above

In the paragraph below, a statement contains two pairs of terms enclosed in parentheses. Determine which term in each pair correctly completes the statement. Then select the answer choice containing the two terms that you have chosen.

In the case of Pacificare of Oklahoma, Inc. v. Burrage, the U.S. Court of Appeals for the Tenth Circuit considered whether ERISA preempts medical malpractice claims against health plans based on certain liability theories. In this case, the Tenth Circuit court held that ERISA (should / should not) preempt a liability claim against an HMO for the malpractice of one of its primary care physicians, and therefore the HMO was subject to a claim of (subordinated / vicarious) liability.

A. Should / subordinated

B. Should / vicarious

C. Should not / subordinated

D. Should not / vicarious

Indigo Health Plan advertised a specific individual health insurance policy through a direct mail advertisement that provided detailed information about the product. In order to comply with theNAIC Model Rules Governing Advertisements of Accident and Sickness Insurance, Indigo must disclose whether the advertised policy contains any exceptions, reductions, or limitations. Thus, Indigo disclosed in the advertisement that one policy provision limits coverage for dental exams to $50 per exam and to one exam per calendar year. This information indicates that, with respect to the definitions in the NAIC Model Rules, Indigo's advertisement is an example of an

A. Invitation to contract, and it discloses a policy provision known as an exception

B. Invitation to contract, and it discloses a policy provision known as a reduction

C. Invitation to inquire, and it discloses a policy provision known as an exception

D. Invitation to inquire, and it discloses a policy provision known as a reduction

Regulators of health plans have set standards in a number of areas of plan operations. Requirements with which health plans must comply typically include

A. providing enrollees and prospective enrollees with detailed information about various aspects of health plan policies and operations

B. maintaining internal grievance and appeals processes to resolve enrollee complaints against the organization

C. maintaining quality assurance programs that reflect the plan's activities in monitoring quality

D. all of the above