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【SOA真题】北美2014精算师：November2003Course8M（五）

来源：高顿网校 2014-07-18

　　高顿网校小编提醒亲们，把握好北美精算师的考试题型，就不会心慌意乱了，合格证手到擒来。
　　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赠言：人生如同道路。最近的捷径通常是最坏的路。 —— 培根

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