请时刻监督我们每日更新北美精算师考试大纲的各种内容哦：SOA真题系列荟萃Course8M2004November北美精算师第二课。
　　8. (5 points) LMN Company employees currently utilize two different networks. Both
　　networks use the same pharmacy benefits manager, and detailed pharmacy claims data
　　are available. Network A has additional detailed health claims information. The per
　　capita claims cost for Network A is twice as high as in Network B. You have been asked
　　to determine if the higher costs are caused by differences in the enrollee health status.
　　(a) Describe criteria used for health risk classification.
　　(b) Describe risk assessment models currently available.
　　(c) Recommend a risk assessment method for LMN Company.
　　9. (7 points) You are an actuary who recently accepted a non-traditional role as claims
　　manager for a health carrier. You are concerned about the new inventory standards, as
　　measured by turn-around time (TAT) and their impact on quality. Additionally, you are
　　concerned about common claims problems and the lack of documented procedures and
　　guideline for working with other departments.
　　(a) Regarding TAT:
　　i. Define TAT.
　　ii. Describe considerations used when establishing TAT goals.
　　iii. Describe the tools used for tracking and monitoring TATs.
　　(b) Regarding quality:
　　i. Define the measures of claim quality.
　　ii. List the steps of claim quality review process.
　　iii. Describe the major issues to consider when performing a quality audit.
　　(c) Describe common claims and benefit administration problems.
　　(d) List the items requiring procedures and guidelines for coordination of the claim
　　department with the following departments:
　　i. Enrollment and billing
　　ii. Provider relations
　　iii. Utilization management
　　iv. Member services
　　v. Finance
　　COURSE 8: Fall 2004 - 7 - STOP
　　Health, Group Life & Managed Care
　　Morning Session
　　10. (4 points) As a result of the new Medicare Prescription Drug Improvement and
　　Modernization Act of 2003 it may be necessary for a plan sponsor to perform an actuarial
　　valuation to determine actuarial equivalence between the sponsor’s plan with the basic
　　Medicare benefit.
　　Assume that costs over age 65 for the sponsor’s plan are $1,500 per year and plan costs,
　　on the average, increase by 3% per year above 65. Assume that the demographics are as
　　follows:
　　Demographics
　　Age Group Number
　　65 to 69 200
　　70 to 74 400
　　75 to 79 300
　　80 to 84 100
　　Total 1,000
　　(a) Outline the assumptions needed to perform an actuarial valuation of the sponsor’s
　　plans.
　　(b) Develop the sponsor’s plan costs by age group.
　　(c) Describe the financial impact to the plan sponsor of the three possible outcomes
　　when determining actuarial equivalence.
　　**END OF EXAMINATION**
　　MORNING SESSION
　　COURSE 8: Fall 2004 - 8 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　**BEGINNING OF EXAMINATION**
　　MANAGED CARE SEGMENT
　　AFTERNOON SESSION
　　Beginning With Question 11
　　11. (4 points)
　　(a) Describe the types of claim liabilities and reserves. For each, provide an example
　　of an event which would require such a liability or reserves to be established.
　　(b) Describe common methods used to estimate claim reserves.
　　12. (6 points) Company XYZ management has decided it is time to invest resources into
　　developing better reporting and analytical systems.
　　(a) (2 points) Describe ways data compiled in the claim adjudication process can be
　　used for reporting and analysis.
　　(b) (3 points) Compare and contrast types of data structures and physical media used
　　to store data in computer systems.
　　(c) (1 point) Describe considerations when choosing a data structure and storage
　　media.
　　COURSE 8: Fall 2004 - 9 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　一个能从别人的观念来看事情，能了解别人心灵活动的人永远不必为自己的前途担心。——高顿网校心灵鸡汤