请关注高顿网校，因有更多的*7最全8月的北美精算师考试信息与您分享——北美SOA精算师往届真题November2003Course8M（第九部分）。
　　9. (5 points) You are the pricing actuary for the division of LTDC Life Insurance selling
　　group long term disability and group long term care products. Given the recent
　　fluctuations in the experience, you are considering implementing a reinsurance agreement
　　but must convince your Vice-President that it is needed.
　　(a) Explain the different approaches LTDC Life can use to reinsure its Group LTD
　　and LTC products.
　　(b) Explain risk characteristics of each product line that make the use of reinsurance
　　attractive.
　　**END OF EXAMINATION*
　　MORNING SESSION
　　COURSE 8: Fall 2003 - 7 - GO ON TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　**BEGINNING OF EXAMINATION**
　　MANAGED CARE SEGMENT
　　AFTERNOON SESSION
　　Beginning With Question 10
 
　　10. (3 points) You have been asked to summarize the report of the SOA Medical
　　Effectiveness Task Force.
　　(a) Explain the importance of measuring medical effectiveness.
　　(b) Explain the main health plan performance *uation categories.
　　COURSE 8: Fall 2003 - 8 - GO ON TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
 
　　11. (4 points) Your company offers an insurance product with the following equally likely
　　events.
　　Severity of Claim Given Event Occurs
　　Event
　　Frequency of Claim
　　Given Event Occurs Probability Claim Size
　　1 25% 75%
　　25%
　　1,000
　　500
　　2 50% 50%
　　50%
　　1,000
　　500
　　3 75% 10%
　　90%
　　1,000
　　500
　　You are also given the following additional information:
　　?  7 years of claims history for one individual
　　Year Claims
　　1 -
　　2 500
　　3 -
　　4 -
　　5 1,000
　　6 1,000
　　7 -
　　?  Expected Value of the Process Variance = 133,581
　　?  Target Loss Ratio = 80%
　　?  Ignore the impact of trend
　　(a) Calculate the expected gross premium for this product. Show your work.
　　(b) Calculate the credibility. Show your work.
　　(c) Calculate the credibility weighted total premium for this individual. Show
　　your work.
　　COURSE 8: Fall 2003 - 9 - GO ON TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
 
　　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
 
　　16. (4 points) You are a consulting actuary for Hospital ID1. The Bedford Group is
　　proposing to capitate Hospital ID1 for inpatient hospital services incurred by its
　　members. You have been asked by Hospital ID1 to develop capitation targets for
　　negotiations with the Bedford Group.
　　In addition to information provided in Tables MC-2 and MC-7, you have made the
　　following assumptions:
　　?  administrative expenses: 8% of capitation
　　?  risk charges: 6% of capitation
　　?  the 2002 hospital experience is credible
　　(a) Using an actuarial cost model based on your current provider contract with
　　Bedford Group, calculate the base pmpm cost. Show your work.
　　(b) List key assumptions that should be considered when determining the utilization,
　　average cost and pmpm targets in an actuarial cost model.
　　(c) Describe additional considerations that Hospital ID1 should consider when
　　*uating a capitation proposal.
　　COURSE 8: Fall 2003 - 13 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 15 - 18 pertain to the Case Study
　　17. (12 points) You are an actuary for the Bedford Group. In a meeting with the VP of
　　Provider Contracting, you are told that a large physician specialty group that provides
　　15% of all specialty services has left IPA1 and joined IPA2.
　　Assume that:
　　?  Physician risk share arrangements for 2002 and 2003 do not change.
　　?  For PCP’s in IPA1, the 2002 actual claim cost equals the t
　　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
　　#61485;  Class 1 Bonds $ 9.8 million
　　-  Class 1 Preferred Stock $ 2.2 million
　　-  Common Stock $ 2.0 million
　　Underwriting Revenue/Earned Premium
　　-  Comprehensive Medical & Hospital $45.0 million
　　-  Dental $16.3 million
　　-  ASO Fees $ 5.0 million
　　Claim Payments under:
　　-  capitation (paid directly to providers) $11.0 million
　　-  professional fee schedule $22.7 million
　　-  hospital case rates $10.2 million
　　-  discounted charges $ 8.2 million
　　Underwritten business administrative expenses
　　(excludes premium taxes & commissions)世纪考试网版权所有
　　$ 2.1 million
　　(a) Describe regulatory implications of RBC outcomes.
　　(b) Describe other uses of RBC measurements.
　　(c) Review the variables and formula for health RBC after covariance as used in the
　　RBC Model.
　　(d) Recommend ways to reduce the amount of RBC that Capitalized HP must hold.
　　**END OF EXAMINATION**
　　AFTERNOON SESSION
　　高顿网校之做人原则：漂亮的人怀疑自己的智慧，强有力的人怀疑自己的魅力。——莫罗阿