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。