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SOA精算师考试往年真题发布——November2003Course8M（最后一页）

来源：高顿网校 2014-08-01

　　这是很重要的北美精算师考点大纲：SOA精算师考试往年真题发布——November2003Course8M（最后一页）
　　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

　　i

　　nsurance 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

　　- pro

　　fessional fee schedule $22.7 million

　　- hospital case rates $10.2 million

　　- discounted charges $ 8.2 million

　　Underwritten business administrative expenses

　　(excludes premium taxes & commissions)

　　$ 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
　　高顿网校之做人道理：无论哪一个时代，青年的特点总是怀抱着各种理想和幻想。这并不是什么毛病，而是一种宝贵的品质。

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