One federal law amended the Social Security Act to allow states to set their own qualification standards for HMOs that contracted with state Medicaid programs and revised the requirement that participating HMOs have an enrollment mix of no more than 50% combined Medicare and Medicaid members.

This act, which was the true stimulus for increasing participation by health plans in Medicaid, is called the

A. Omnibus Budget Reconciliation Act of 1981 (OBRA-81)

B. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

C. Employee Retirement Income Security Act of 1974 (ERISA)

D. Federal Employees Health Benefits Act of 1958 (FEHB Act)

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

The Tidewater Life and Health Insurance Company is owned by its policy owners, who are entitled to certain rights as owners of the company, and it issues both participating and nonparticipating insurance policies. Tidewater is considering converting to the type of company that is owned by individuals who purchase shares of the company's stock. Tidewater is incorporated under the laws of Illinois, but it conducts business in the Canadian provinces of Ontario and Manitoba.

Tidewater established the Diversified Corporation, which then acquired various subsidiary firms that produce unrelated products and services. Tidewater remains an independent corporation and continues to own Diversified and the subsidiaries. In order to create and maintain a common vision and goals among the subsidiaries, the management of Diversified makes decisions about strategic planning and budgeting for each of the businesses.

In creating Diversified, Tidewater formed the type of company known as

A. A mutual holding company

B. A spin-off company

C. An upstream holding company

D. A downstream holding company

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

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