高顿网校小编真诚祝您生活快乐，北美精算师考试SOA——November2003Course8M真题（10）的知识点一全部看懂！
　　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.
　　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
　　高顿网校之做人道理：女性行为之美的魅力，其精髓在于情态的温柔。——金马