北美地区November2003Course8M（第七部分）——SOA精算师考试，大家把分值的分布在脑子里呀。
　　12. (4 points) ABC Company is considering acquiring ITSA, a managed care organization
　　that services a number of major cities. You are the head of the claims department in the
　　Major Medical division and you’ve been asked to *uate claims operations at ITSA,
　　including systems used to process the claims.
　　(a) Describe measures of claims quality.
　　(b) Outline basic steps you would expect to find in the ITSA claims adjudication
　　process.
　　(c) Describe specific internal data sources you should include as part of your claims
　　review.
　　(d) Describe issues that should be considered in performing an audit.
　　13. (4 points) You have been asked by your client at BEST HMO to create a presentation that
　　will enable her to convince management to establish new methods for physician
　　compensation.
　　(a) Describe traditiona l and new, alternative forms of capitation and their suitability
　　for specific types of physicians.
　　(b) Describe traditional and new, alternative forms of incentive plans.
　　COURSE 8: Fall 2003 - 10 - GO ON TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　14. (5 points) You are a consultant hired by TeethFerry.com, a company hoping to use the
　　Internet to market dental plans. They have created a marketing communication to be sent
　　to companies that do not currently have a benefits program.
　　From: TeethFerry
　　.com
　　Subject: Quality Dental Coverage with 3 Months at No Charge
　　Affordable Dental Coverage
　　?  save up to 60% on all your dental needs
　　?  choose from 15 of the finest nationwide and regional plans
　　?  pay premiums, submit claims, get the latest information, all on your desktop!
　　(a) List the general types of delivery systems for dental plans and their major
　　features.
　　(b) Outline plan provisions and claim practices that dental insurers can use to
　　limit cost and anti-selection.
　　(c) Describe challenges that e-commerce companies must overcome to be世纪考试网版权所有
　　successful.
　　COURSE 8: Fall 2003 - 11 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 15 - 18 pertain to the case study
　　15. (4 points) The Bedford Group is exploring alternatives to acute inpatient care. A study
　　by Bedford’s Medical Director indicates the MCO might benefit from a program to
　　encourage patients with conditions requiring less intensive treatment to be moved from
　　acute care facilities to a Skilled Nursing Facility (SNF). The initiative would transfer
　　acute care patients to the SNF at Hospital ID1 and is expected to result in the following
　　changes:
　　Reduction in
　　Medical Acute Days
　　Reduction in
　　Surgical Acute Days
　　Hosp ID1 1.0% 0.5%
　　Hosp ID2 2.0% 2.0%
　　Hosp ID3 1.5% 1.0%
　　(a) Assuming the above reductions are realized, and based on Table MC-2, calculate
　　the expected change in medical, surgical and SNF days/1000 and the change in
　　medical/surgical length of stay in 2002 for the MCO. Show your work.
　　(b) Describe behavioral health channeling mechanisms available to direct individuals
　　to the appropriate type of care.
　　COURSE 8: Fall 2003 - 12 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 15 - 18 pertain to the case study
　　北美精算师
　　COURSE 8: Fall 2003 -1- GO TO NEXT PAGE
　　Health, Group Life & Managed Care
　　Morning Session
　　**BEGINNING OF EXAMINATION**
　　HEALTH, GROUP LIFE & MANAGED CARE
　　MORNING SESSION
　　1. (4 points) Your CEO is departing for a meeting to discuss the marketing strategy for a
　　new managed care product. He has asked you to brief him on the following topics:
　　(a) With regard to distribution models
　　(i) Describe traditional and alternative distribution models.
　　(ii) Describe considerations relative to the major constituent groups that
　　influence the distribution process.
　　(b) Describe market segments commonly used for managed care products.
　　Questions 2 – 8 pertain to the Case Study
　　2. (9 points) You have been asked to analyze the claim experience for Wonderful Life in
　　Tables MM-6a and MM-6b of the case study.
　　(a) Describe the impact on trend of company-specific care management initiatives.
　　(b) Calculate the year-over- year quarterly rolling trend for 3Q02 and 4Q02.
　　(c) Recommend baseline trends for Hospital, Non-Hospital and Total Medical Costs.
　　Assume the last half of 2002 is predictive of future trends. Justify your answer.
　　(d) Based on the following assumptions:
　　?  On January 1, 2003, 50% of the hospitals will accept 10% discount off the
　　2003 Hospital contracted rate.
　　?  These hospitals deliver 1/3 of your facility care.
　　?  The remaining hospital contract costs will increase as expected.
　　?  Utilizatio n does not change.
　　Calculate a revised estimate of Hospital and Total Medical Trend. Show your
　　work.
　　(e) Marketing has just sold a large group with 5,000 employees (12,000 members).
　　All of the group members will only use hospitals that accept the 10% discount.
　　Calculate a revised estimate of Total Medical Trend. Show your work.
　　COURSE 8: Fall 2003 -2- GO TO NEXT PAGE
　　Health, Group Life & Managed Care
　　Morning Session
　　Questions 2 – 8 pertain to the Case Study
　　3. (13 points) You are a consultant for Bailey Industries. Bailey has been struggling to
　　balance increased medical costs against emplo yee demand for more choice in coverage.
　　Bailey is considering the adoption of a new medical plan with patient-directed benefits.
　　In addition to Table B-1, you are given the following claims probability distribution and
　　proposed benefit options:
　　Claims Range Percentage of Employees
　　with claims cost in range
　　Average claims cost per
　　employee in range
　　$0 15% 0
　　$1 - $1,000 40% $400
　　$1,000 - $2,000 15% $1,500
　　$2,000 - $5,000 15% $3,500
　　$5,000+ 15% $25,000
　　Option A Option B
　　Deductible $1,000 $2,000
　　Coinsurance 10% 20%
　　Annual Employee
　　Premium $0 $0
　　Employer funds placed
　　in Employees PHA
　　$500 $1,250
　　(a) (1 point) Describe problematic aspects of the current employer-sponsored system
　　for employers and employees.
　　(b) (3 points) Describe key implementation considerations for an employer adopting a
　　PDHB approach and how they would apply to Bailey Industries.
　　(c) (3 points) Describe models used to predict selection costs for the medical options.
　　Identify and explain why certain models are not appropriate for *uating costs
　　for Bailey Industries.
　　(d) (6 points) Assume a group of all single employees who, absent choice, would be
　　equally distributed between the two options. Assume PHA (Personal Health
　　Account) funds are expenses to Bailey Industries.
　　(i) Construct a choice model for Options A&B and calculate maximum
　　adverse selection cost.
　　(ii) Explain why adverse selection will be less than the amount calculated by a
　　choice model.
　　(iii) Describe methods to manage adverse selection in PDHB models.
　　COURSE 8: Fall 2003 -3- GO TO NEXT PAGE
　　Health, Group Life & Managed Care
　　Morning Session
　　Questions 2 – 8 pertain to the Case Study
　　高顿网校之名人信念：品位这东西为气为魂为筋骨为神韵，只可意会。——张抗抗