精算师的考生们，你们好，欢迎前来阅读，本资料是由高顿网校小编为您呈现的。
　　COURSE8:Fall2004-1-GOTONEXTPAGE
　　Health,GroupLife&ManagedCare
　　MorningSession
　　**BEGINNINGOFEXAMINATION**
　　HEALTH,GROUPLIFE&MANAGEDCARE
　　MORNINGSESSION
　　1.(4points)Youareanactuaryforareinsurancecompany.Abusinessschoolprofessorat
　　alocaluniversityhasinvitedyoutobeaguestlectureronthetopic,“Reinsurance
　　ProgramManagement.”
　　Outlineanddescribethecontentsofyourpresentation,withrespectto:
　　i.informationareinsurancecompanyshouldseekinordertodecidewhetherto
　　offerreinsurancetoacustomer
　　ii.practicesareinsurershouldfollowtomaintainaprofitablereinsuranceportfolio.
　　2.(5points)YouhavebeenaskedbyyourlocalChamberofCommercetospeakonthe
　　topicofpatient-directedhealthcarebenefitprograms(PDHBs).
　　(a)DescribekeyfeaturesoftheprincipaltypesofPDHBs.
　　(b)ContrastvariationsbetweentypesofPDHBswithrespectto:
　　i.extenttowhichconsumersperceivemoneyspentastheirownwhen
　　makinghealthcarecostandvaluejudgments,
　　ii.consumerflexibilityindirectingtheuseofemployer-providedand
　　personalhealthcarefunds,
　　iii.extentofemployerinvolvementinplandesignandadministration.
　　(c)IdentifypossiblechangesintheU.S.taxrulesthatcouldencouragetheuseof
　　PDHBs.
　　COURSE8:Fall2004-2-GOTONEXTPAGE
　　Health,GroupLife&ManagedCare
　　MorningSession
　　Questions3–6pertaintotheCaseStudy
　　3.(8points)YouarethepricingactuaryforWonderfulLifeandhavebeenaskedbythe
　　underwriterassignedtoGroup6tohelpherprepareforameetingwiththegroup’sCFO.
　　InadditiontoTablesMM-2bandMM-3b,youhavebeengiventhefollowing
　　information:
　　PriorRatingPeriodData:ExperienceperiodJuly1,2001throughJune30,2002
　　Group6CompositeAge/SexFactor
　　Option11.03
　　Option20.85
　　(a)Describemacro-economicvariablesthatmayaffecthealthcaretrendrates.
　　(b)Describeothertrendcomponentsthatmaycausetrendstovary.
　　(c)Discusstherelationshipofhistoricaltrendsandratingtrendassumptions.
　　(d)CalculatethetotalpercentageincreaseinGroup6’sclaimscostperemployeeand
　　calculatecomponentsoftheirclaimstrendforwhichsufficientdataareavailable.
　　COURSE8:Fall2004-3-GOTONEXTPAGE
　　Health,GroupLife&ManagedCare
　　MorningSession
　　Questions3–6pertaintotheCaseStudy
　　4.(6points)YouareanunderwriterforWonderfulLifepreparingaproposalforBailey
　　Industriestoreplacetheircurrentdentalplanwithamanageddentalcareplan.
　　BaileyIndustriesgoalsareasfollows:
　　?  limitcomplexity
　　?  avoidadverseselection
　　?  avoidemployeedissatisfactionduetoproviderdisruption
　　?  maintaincurrentemployercontributionsandplandesign
　　(a)Describethefeaturesforeachofthegeneraltypesofdentalbenefitdelivery
　　systems.
　　(b)Developachartrankingtheplantypesalongthefollowingparameters:premium,
　　patientaccess,benefitrichness,costmanagement,utilization,qualityassurance,
　　andfraudpotential.
　　(c)EvaluatethepossibledeliverysystemsbasedonBaileyIndustriesgoalsandmake
　　arecommendationastoadeliverysystem.Justifyyourresponse.
　　COURSE8:Fall2004-4-GOTONEXTPAGE
　　Health,GroupLife&ManagedCare
　　MorningSession
　　Questions3–6pertaintotheCaseStudy
　　5.(9points)YouareanunderwriterwithWonderfulLifepreparingtherenewalfor
　　Group4.
　　AssumethattheretrospectiveformulabalanceinTableMM-3aisasoftheendofthe
　　experienceperiodandthatpricingfactorsasshowninTableMM-2aandMM-2bhave
　　notchanged.
　　(a)CalculateGroup4’sprojectedretrospectiveformulabalanceasofDecember31,
　　2003usingthesameassumptionsaswouldbeusedforrating.Showyourwork.
　　(b)CalculatetheEEonlyandEEandDependentsmonthlyrenewalpremiumsfor
　　2004.Showyourwork.
　　(c)Discusstheprosandconsofvariousfundingarrangements,bothfroman
　　employer’spointofviewandspecificallyforGroup4,
　　i.prospectiveexperiencerating,
　　ii.retrospectiveexperiencerating,
　　iii.self-insurance,and
　　iv.minimumpremiumplans.
　　6.(5points)Youare*uatingWonderfulLife’sreservesusingNon-Hospitalclaimspaid
　　inTablesMM-4candMM-4d.AssumethattheJuly2002completionpatternis
　　representativeofallmonths.
　　(a)CalculatetheincurredclaimsforincurredmonthsJuly2003throughDecember
　　2003usingage-ultimatedevelopmentfactors.Showyourwork.
　　(b)CalculatetheIBNRasofDecember31,2003forincurredmonthsJuly2003
　　throughDecember2003.Showyourwork.
　　(c)RecommendadjustmentstothisapproachwhichmightproducereasonableIBNR
　　results.
　　COURSE8:Fall2004-5-GOTONEXTPAGE
　　Health,GroupLife&ManagedCare
　　MorningSession
　　7.(7points)Youarethehealthactuaryreviewingthepricingassumptionsandthefirst
　　threeyearsofexperienceforagivenproduct.Thefollowinginformationisgiven:
　　ClassicalPricingAssumptions
　　ProductDuration:5Years
　　interestrates:0.0%
　　annuallapserate:20.0%
　　targetlossratio:60.0%
　　tabularclaimscost
　　DurationTabularClaimsCostSelectionAdjustment
　　010.0.05
　　111.01.1
　　212.01.1
　　313.01.1
　　414.01.1
　　ExperienceData
　　DurationMbrsActualClaims
　　01,0006,000
　　177010,000
　　265011,000
　　3500-
　　4350-
　　CumulativeAntiselectionTheoryAssumptions
　　K1=-
　　K2=4
　　u0.10
　　(a)(1point)DescribehowCASTdiffersfromclassical(selectandultimate)theory.
　　(b)(2points)Calculatethegrosspremiumusingtheclassicalpricingassumptions.
　　Showyourwork
　　(c)(4points)CalculatethegrosspremiumusingCASTassumptions.Showyour
　　work.
　　COURSE8:Fall2004-6-GOTONEXTPAGE
　　Health,GroupLife&ManagedCare
　　8.(5points)LMNCompanyemployeescurrentlyutilizetwodifferentnetworks.Both
　　networksusethesamepharmacybenefitsmanager,anddetailedpharmacyclaimsdata
　　areavailable.NetworkAhasadditionaldetailedhealthclaimsinformation.Theper
　　capitaclaimscostforNetworkAistwiceashighasinNetworkB.Youhavebeenasked
　　todetermineifthehighercostsarecausedbydifferencesintheenrolleehealthstatus.
　　(a)Describecriteriausedforhealthriskclassification.
　　(b)Describeriskassessmentmodelscurrentlyavailable.
　　(c)RecommendariskassessmentmethodforLMNCompany.
　　9.(7points)Youareanactuarywhorecentlyacceptedanon-traditionalroleasclaims
　　managerforahealthcarrier.Youareconcernedaboutthenewinventorystandards,as
　　measuredbyturn-aroundtime(TAT)andtheirimpactonquality.Additionally,youare
　　concernedaboutcommonclaimsproblemsandthelackofdocumentedproceduresand
　　guidelineforworkingwithotherdepartments.
　　(a)RegardingTAT:
　　i.DefineTAT.
　　ii.DescribeconsiderationsusedwhenestablishingTATgoals.
　　iii.DescribethetoolsusedfortrackingandmonitoringTATs.
　　(b)Regardingquality:
　　i.Definethemeasuresofclaimquality.
　　ii.Listthestepsofclaimqualityreviewprocess.
　　iii.Describethemajorissuestoconsiderwhenperformingaqualityaudit.
　　(c)Describecommonclaimsandbenefitadministrationproblems.
　　(d)Listtheitemsrequiringproceduresandguidelinesforcoordinationoftheclaim
　　departmentwiththefollowingdepartments:
　　i.Enrollmentandbilling
　　ii.Providerrelations
　　iii.Utilizationmanagement
　　iv.Memberservices
　　v.Finance
　　COURSE8:Fall2004-7-STOP
　　Health,GroupLife&ManagedCare
　　MorningSession
　　10.(4points)AsaresultofthenewMedicarePrescriptionDrugImprovementand
　　ModernizationActof2003itmaybenecessaryforaplansponsortoperformanactuarial
　　valuationtodetermineactuarialequivalencebetweenthesponsor’splanwiththebasic
　　Medicarebenefit.
　　Assumethatcostsoverage65forthesponsor’splanare$1,500peryearandplancosts,
　　ontheaverage,increaseby3%peryearabove65.Assumethatthedemographicsareas
　　follows:
　　Demographics
　　AgeGroupNumber
　　65to69200
　　70to74400
　　75to79300
　　80to84100
　　Total1,000
　　(a)Outlinetheassumptionsneededtoperformanactuarialvaluationofthesponsor’s
　　plans.
　　(b)Developthesponsor’splancostsbyagegroup.
　　(c)Describethefinancialimpacttotheplansponsorofthethreepossibleoutcomes
　　whendeterminingactuarialequivalence.
　　**ENDOFEXAMINATION**
　　MORNINGSESSION
　　COURSE8:Fall2004-8-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　**BEGINNINGOFEXAMINATION**
　　MANAGEDCARESEGMENT
　　AFTERNOONSESSION
　　BeginningWithQuestion11
　　11.(4points)
　　(a)Describethetypesofclaimliabilitiesandreserves.Foreach,provideanexample
　　ofaneventwhichwouldrequiresuchaliabilityorreservestobeestablished.
　　(b)Describecommonmethodsusedtoestimateclaimreserves.
　　12.(6points)CompanyXYZmanagementhasdecideditistimetoinvestresourcesinto
　　developingbetterreportingandanalyticalsystems.
　　(a)(2points)Describewaysdatacompiledintheclaimadjudicationprocesscanbe
　　usedforreportingandanalysis.
　　(b)(3points)Compareandcontrasttypesofdatastructuresandphysicalmediaused
　　tostoredataincomputersystems.
　　(c)(1point)Describeconsiderationswhenchoosingadatastructureandstorage
　　media.
　　COURSE8:Fall2004-9-GOTONEXTPAGE
　　ManagedCareSegment
　　13.(5points)YouaretheCFOofastart-upinsurancecompany.Youareintheprocessof
　　determiningyourminimumrequiredsurplusanddesigningasystemformeasuring
　　capital,profit,andgrowth.
　　(a)Describetheinsurancerisksthatshouldbeconsideredwhensettingminimum
　　surplusrequirements.
　　(b)Discussthenecessaryconsiderationswhendesigningasystemformeasuring
　　capital,profit,andgrowth.
　　(c)Discussandillustratewithformulashowcapital,profit,andgrowthinter-relate.
　　COURSE8:Fall2004-10-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　14.(5points)PaulandLeslie,whoarebothintheir30’s,wererecentlymarriedandare
　　meetingwithanagenttodiscusstheirfinancialplans.
　　Paulworksoncontractasamotivationalspeakerandhasnoemployeebenefits.Heearns
　　$50,000ayear.Leslieworksforafinancialinstitutionwhichhasaflexiblebenefitsplan
　　includingSTDandLTD.Leslieearnsabasesalaryof$50,000peryearandearneda
　　bonusof$5,000lastyear.
　　Paulisconsideringthefollowingdisabilityplan:
　　Type:IndividualDisabilityIncome
　　WaitingPeriod:30days
　　DefinitionofDisability:Ownoccupationto65
　　BenefitAmount:$2500permonth
　　BenefitTerm:5years
　　Leslieiscurrentlyenrolledinthefollowingoptionintheflexplan:
　　Type:LTDSTD
　　EliminationPeriod:4months
　　DefinitionofDisability:2YearOwnOccupation,
　　thenAnyOccupationto65
　　BenefitAmount:60%ofsalary100%ofsalaryfor2
　　months,75%ofsalary
　　thereafter
　　Funded:100%Employeepaid
　　Indexing:3%perannumondisability
　　anniversary
　　(a)Compareandcontrasttheunderwritingcriteriausedforindividualandgroup
　　disabilitypolicies.
　　(b)DescribehowthesecriteriawouldapplyspecificallytoPaulandLeslie.
　　(c)DescribehowbenefitswouldbedeterminedandcalculatePaulandLeslie’s
　　cashflowiftheywerebothinjuredinacaraccidentandwereunabletoworkfor5
　　years.Showyourwork.
　　COURSE8:Fall2004-11-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　15.(6points)YouareaconsultingactuaryfortheHealthInsuranceCompanyof
　　UnaffiliatedProviders(HICUP).TheChiefActuaryofHICUPisconsideringentryinto
　　theMedicarePlusChoice(M+C)marketintheirareaandapproachedyouforadvice.
　　TheywanttoofferM+CcoverageinGoldenYearsCountywhereover70%ofresidents
　　areofretirementage.TherearealreadytwoothercompaniesofferingM+Cpoliciesin
　　thisarea.SinceHICUPdoesnothaveexperienceintheM+Cmarket,youhavebeen
　　askedtoprepareareporttodiscussrequirementsofentryintothismarket.Youhave
　　explainedthatMedicarePlusChoiceisnowknownasMedicareAdvantageandHCFAis
　　nowknownasCMS.Althoughtherewillbefurtherchangesintheprogram,youhave
　　basedyourinitialreportonthe2004rules.
　　(a)Outlineandprovidedetailsofspecificrulesrequiredbylegislationtoenterintoa
　　M+CcontractanddecisionsHICUPwillneedtomakeatentry.
　　(b)ContrastotherproductoptionsavailabletoHICUPfortheseniorpopulationand
　　theiradvantagesanddisadvantages.
　　(c)OutlinetheCMSM+Cfilingprocessandpaymentmechanismwithsufficient
　　detailsfortheChiefActuarytomakeapresentationtoHICUP’sBoard.
　　16.(5points)YouareaconsultingactuarytoABCHMO.TheCEOhasaskedyouto
　　provideareport*sinapproachestoaddressingbehavioralhealthbenefits
　　providedbymanagedcareplans.
　　(a)Discussemergingstrategicapproachestomanagingbehavioralhealthbenefits.
　　(b)OutlinestrategiesMCOsareusingtoimproveclinicaloutcomes.
　　(c)Describeutilizationreviewandcasemanagementtechniquesconsistentwiththese
　　strategies.
　　(d)Discussconsiderationsyouwouldmaketodeterminewhetheracapitated
　　arrangementtoabehavioralhealthspecialtygroupisappropriatefortheir
　　business.
　　COURSE8:Fall2004-12-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　Questions17–19pertaintotheCaseStudy
　　17.(5points)ThePCPsofIPA3areconsideringjoiningIPA1.
　　(a)DiscussreimbursementstructuresforPCPsandadvantagesanddisadvantagesof
　　eachfromthePCP’sperspective.
　　(b)DiscussadvantagesanddisadvantagesforIPA3PCPsinjoiningIPA1and
　　recommendactionsIPA3PCPscouldtaketoaddressthedisadvantages.
　　(c)DiscussadvantagesanddisadvantagesfromtheBedfordGroup’sperspectiveof
　　thepotentialshiftofIPA3PCPstoIPA1.
　　COURSE8:Fall2004-13-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　18.(7points)TheBedfordGroupisrenegotiating2004providercontracts.Thecontracting
　　unitisproposingreimbursementincreasestoHospitalID2of15%forMedicaland
　　Surgicaland10%forallotherservices.Inaddition,theMedicalDirectorhasreviewed
　　HospitalID2MedicalandSurgicalchartsanddeterminedthefollowing:
　　ChartReviewResults
　　?  5%ofadmitsareunnecessary
　　?  15%ofdaysareunnecessary
　　?  ExcessadmitsanddaysareevenlydistributedbetweenMedicalandSurgical
　　services
　　UsingTablesMC-2,MC-3,MC-4,andMC-7
　　(a)(3points)CalculatethereimbursementforunnecessarycareprovidedatHospital
　　ID2for2003.Showyourwork.
　　(b)(3points)Forecast2004paymentstoHospitalID2formedicalandpsychiatric
　　servicesthatreflect:
　　?  proposedhospitalreimbursementincreases,
　　?  allpotentialutilizationsavingsfromthechartreview,
　　?  budgetedutilizati*sforpsychiatricservices
　　Showyourwork.
　　(c)(1point)DescribeissuesregardinghospitalclaimsubmissionsfacedbyMCOs
　　andclaimreviewmethodsusedtoidentifyandaddresstheseissues.
　　COURSE8:Fall2004-14-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　Questions17–19pertaintotheCaseStudy
　　19.(7points)AstheCFOoftheBedfordgroupyouareconcernedaboutthevolatilityof
　　EarningsBeforeTaxesasshowninTableMC-1.InadditiontotheinformationTable
　　MC-1,youareprovidedthefollowing:
　　MembershipChangeNonefor2004or2005
　　Expected2004PremiumIncrease6%
　　PaidClaimsTrend10%peryearfor2004and2005
　　IBNREstimate2.0monthsofprior12monthspaidclaims
　　AdminTrend3%peryearfor2004and2005
　　AveragePremiumTax1%ofpremiumfor2004and2005
　　InvestmentIncomeRate3%peryearfor2004,4%for2005
　　Corporatetaxrate0%for2004and2005
　　Surplusatendof2003$350,000,000
　　Assumenochangestothe2003IncomeStatementandBalanceSheetotherthanthose
　　listedabove.
　　(a)(6points)TheBoardisexpecting2005OperatingEarningstobe5%ofpremium.
　　Developtheoverall2005premiumincreaseneededtomeetthisgoal.
　　Showyourwork.
　　(b)(1point)Describesourcesotherthanpremiumthatcanbeusedtoincrease
　　OperatingEarnings.
　　COURSE8:Fall2004-15-GOTONEXTPAGE
　　ManagedCareSegment
　　AfternoonSession
　　20.(3points)YouarethechiefactuaryforXYZmanagedcarecompany.Youhave
　　observedaveryhightrendinambulatorycareservicesandwanttoimplementaseries
　　reportstoanalyzeandaddressthisissue.YourChiefMedicalOfficerisconcernedabout
　　thereactionofproviderstobeingprofiled.
　　(a)Liststatisticalconsiderationswhenchoosinganambulatorycasemixsystem.
　　(b)Describegeneraltypesofreportsyouwoulddevelopforplanmanagementof
　　providercosts.
　　(c)Defineproviderprofiling,identifyitsuses,andlisttheprinciplesyourprovider
　　profilingsystemwillfollowtoensurethatthereportsarefairanduseful.
　　21.(4points)Youareanactuaryforahealthcarrierthatwantstoaddadiseasemanagement
　　programtohelpcontrolcostsandattractmoreself-fundedemployerbusiness.
　　(a)Describecharacteristicsthatcontributetoasuccessfuldiseasemanagement
　　program.
　　(b)Describebarriersanddriversforimplementationofadiseasemanagement
　　program.
　　(c)Listthefeaturesthatdistinguishdiseasemanagementfromconventionalmedical
　　management.
　　(d)ExplainpotentialrisksinvolvedwithusingtheInternetasadiseasemanagement
　　tool.
　　COURSE8:Fall2004-16-STOP
　　ManagedCareSegment
　　AfternoonSession
　　22.(3points)Youareaconsultingactuaryassistingagroupofphysicianstodetermine
　　whetherthegroupshouldformafeeforserviceorprepaidpractice.
　　(a)Comparemajorrisksforaprepaidpracticerelativetoafeeforservicepractice.
　　(b)Outlinealternativesthegroupcouldusetomanageprepaidfinancialrisk.
　　
　　以上则是【北美精算师】历年SOA真题之November2004Course8M，请认真看题、答题与牢记章节重点。
　　
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