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北美精算师考试SOA——November2003Course8M真题（10）

来源：高顿网校 2014-08-01

　　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

　　evaluating 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 evaluating 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

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