下文的北美2014年度精算师——SOA珍藏真题November2003Course8M（第五部分），请尽力早看完。然后抓紧时间看其他章节哦。
　　arget claim cost.
　　Using Tables MC-5, MC-7, and MC-8, and based on 2002 experience:
　　(a) Adjust the 2003 risk share arrangements for IPA1 and IPA2 to reflect the
　　provider change. Show your work.
　　(b) Calculate the expected 2003 payments to IPA1 and IPA2 based on the
　　specialty group shift to IPA2, including any risk share adjustments and
　　ignoring trend. Show your work.
　　(c) Excluding any risk share arrangements, calculate the new percent of
　　Medicare reimbursement to IPA2 to maintain pmpm costs for the Bedford
　　Group at the 2002 level. Show your work.
　　(d) In case IPA2 does not accept a change to their Medicare reimbursement
　　level, you would consider offering a specialty capitation arrangement.
　　Discuss the advantages and disadvantages of a specialty capitation
　　arrangement.
　　COURSE 8: Fall 2003 - 14 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 15 - 18 pertain to the case study
 
　　18. (6 points) You are the pricing actuary for the Bedford Group and have been asked by the
　　Marketing Director to develop new pharmacy premiums. She is interested in having a
　　more competitively priced product. Yo ur CFO has indicated that your profit goal is 2.5%
　　of premium.
　　Assume the HMO and POS plans have identical plan formularies with the following
　　copays:
　　?  Generic $10
　　?  Formulary Brand $20
　　?  Non-Formulary $40
　　Using 2003 budgeted experience from Table MC-4, information provided on Table MC-7,
　　and assuming AWP = $80, then:
　　(a) Calculate the premium if Bedford:
　　(i) retains all rebates.
　　(ii) uses all rebates to reduce premiums.
　　(b) Describe the purposes of rebates, issues surrounding rebates, and actions which
　　can be taken to increase rebates.
　　COURSE 8: Fall 2003 - 15 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
 
　　19. (5 points) You are a consulting actuary for an HMO that wishes to control utilization, yet
　　maintain high quality of care.
　　(a) Describe traditional approaches to quality assessment.
　　(b) Review regulatory issues relating to quality assurance and their impact on HMOs.
　　(c) Describe managed care methods used to control medical utilization and the types
　　of services impacted by each method.
　　(d) Review state regulations that may limit an HMOs ability to manage utilization
　　and costs.
 
　　20. (4 points) You serve on a professional task force advising a State Senator on health
　　insurance reform issues. New health reform legislation is being proposed which is
　　intended to meet the following objectives:
　　?  Promote a reduction in the working uninsured population
　　?  Promote job mobility
　　?  Facilitate the ability of individuals and small employers to compare insurance
　　policies offered by different health carriers
　　?  Reduce variation in, and volatility of premium rates charged to different groups
　　(a) Describe key recommendations regarding the above objectives to be included in
　　reform legislation.
　　(b) The legislature is also reviewing risk adjustment mechanisms for Medicaid HMO
　　plans. Compare and contrast methods of risk adjustment and recommend a
　　method to be included in the legislation. Justify your recommendation.
　　COURSE 8: Fall 2003 - 16 - STOP
　　Managed Care Segment
　　Afternoon Session
 
　　21. (5 points) You are a consulting actuary retained by Capitalized Health Plan, a licensed
　　HMO in a state that has passed the NAIC Risk-Based Capital For Health Organizations
　　Model Act (RBC Model). The CFO is unfamiliar with risk-based capital and has asked
　　you to make a presentation to educate him and his staff. In your research, you have
　　extracted the following information from Capitalized HP’s 2002 Statutory Annual
　　Statement:
　　Assets (Non-Affiliated)
　　-  U.S. Government Bonds $ 4.6 million
　　高顿网校之淳淳教诲指导：一个青年要是相信他日后必定成个不朽的文学家，他心里自然会感到无比的快慰：这可以说是人生再甜蜜不过的时刻。这种抱负的确是很高贵，然而可惜的是，根基往往是太不牢靠了。 —— 马克·吐温