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COURSE 8: Fall 2005 -1- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
**BEGINNING OF EXAMINATION**
HEALTH, GROUP LIFE %26amp; MANAGED CARE
MORNING SESSION
1. (3 points)
(a) Explain non-financial uses of reinsurance.
(b) Describe limitations of reinsurance.
COURSE 8: Fall 2005 -2- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
2. (3 points) You are the actuary for a US health insurance company. You have been asked
to make a presentation to your Board of Directors regarding the regulatory environment
for your company.
(a) Describe goals and objectives of insurance regulation.
(b) Describe the legal framework for insurance regulation and means of enforcement.
COURSE 8: Fall 2005 -3- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
3. (7 points) You are a consulting actuary retained by an employer group. Following the
presentation of renewal rates to the group, you have been asked to attend a meeting to
review trend calculations.
You are given the following information:
%26#8226; Allowed trend: 15%
%26#8226; Incurred claims: $5,250,000
%26#8226; Average monthly membership of the group: 2,000 members
%26#8226; The current plan is Plan A, but the group is considering Plan B:
Plan A Plan B
Deductible $250 $1,500
Coinsurance 20% 30%
Value of the member cost sharing (PMPM) $50 $100
%26#8226; Assume the value of the deductible does not vary from year to year.
(a) Describe in detail external sources of trend that you think might be helpful in your
trend discussion.
(b) Describe common problems in computing trends that you might need to
investigate.
(c) Calculate the net trend for the two plans and explain why there might be a
difference. Show your work.
(d) Describe major issues which might need to be addressed if Plans A and B were to
both be offered as a dual option.
COURSE 8: Fall 2005 -4- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
Questions 4-7 pertain to the Case Study
4. (7 points) You are the actuary at Wonderful Life and have received a request for
proposal from JLB Company (JLB) for a multi-option health quote effective January 1,
2005. JLB currently offers only a $100 deductible indemnity plan.
Using data found in Tables MM-2a and MM-2b and the following additional information:
%26#1048707; Total claims incurred for July 1, 2003 to June 30, 2004 were $4,063,000.
%26#1048707; Claim amounts in excess of $50,000 were $278,000.
%26#1048707; Average employee enrollment during this period was 500 single and 750 family
contracts.
%26#1048707; Wonderful Life’s PPO network discount is 30%.
%26#1048707; In-network utilization is 85%.
%26#1048707; Use of the network reduces utilization by 5% as compared to indemnity.
(a) Discuss pricing considerations in a multi-option environment.
(b) Calculate 2-tier gross premium rates for a $100 deductible indemnity option, and
a $500 deductible PPO option, assuming no selection impact. Show your work.
(c) Outline considerations if JLB’s current plan was a managed care plan instead of
an indemnity plan.
COURSE 8: Fall 2005 -5- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
Questions 4-7 pertain to the Case Study
5. (9 points) Wonderful Life’s management is evaluating the company’s profit and surplus
requirements. You are given the data in Table C-1 and the assumption that Risk-Based
Capital (RBC) is 18% of premium.
(a) (1 point) Discuss methods of measuring profit.
(b) (2 points) Discuss distortions that may require adjustment to avoid
misrepresentation of profits.
(c) (3 points) Describe implications of the following when modeling required surplus
for Wonderful Life:
i. Reinsurance strategy
ii. Dividend philosophy
iii. Expense management controls
iv. Premium growth
(d) (3 points) Determine if Wonderful Life achieved the targeted 12.5% return on
equity for 2004. Show your work.
COURSE 8: Fall 2005 -6- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
Questions 4-7 pertain to the Case Study
6. (9 points) You are the group pricing actuary for Wonderful Life Insurance Company.
You are preparing a proposal for Bailey Industries which includes an analysis of prior
experience. You are given the data in Table BI-1b and the following assumptions:
%26#8226; The only items causing differences in claims costs are plan design and utilization
differences caused by plan design.
%26#8226; The average members per contract for both the PPO and HMO plans is 2.2.
%26#8226; Member Cost as a percentage of claims is as follows:
Utilization
Adjustment Range
Member Cost
Sharing Range
Service Type % of Cost Low High Low High
Facility 50.0% 0.0% 5.0% 0.0% 25.0%
Professional 30.0% -5.0% 20.0% 0.0% 40.0%
Pharmacy 20.0% 0.0% 20.0% 0.0% 25.0%
Total 100.0%
Average Member Cost Sharing
Service Type PPO HMO
Facility 17.5% 0.0%
Professional 25.0% 5.0%
Pharmacy 18.0% 18.0%
(a) (3 points) Describe the criteria that Wonderful Life would use to underwrite
Bailey Industries.
(b) (2 points) Describe the models you might use to predict selection in a multioption
environment.
(c) (4 points) Calculate the expected change in utilization for the HMO plan using
the member utilization cost model. Show your work.
COURSE 8: Fall 2005 -7- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
Questions 4-7 pertain to the Case Study
7. (7 points) You are an actuary at Wonderful Life and have been asked to discuss sources
of profit using Group 1 data as an example.
In addition to the data in Tables MM-1, MM-2a, MM-2b, and MM-3a, assume:
%26#8226; Single/Family manual rates for 2005 are the result of trending historical manual rates.
%26#8226; Expenses, taxes, and investment income are expressed as the percentages from Table
MM-1 for 2004.
(a) Discuss major factors affecting financial results for the group line of business.
(b) Outline the various sources of profit for group insurance.
(c) Calculate profits by source for Group 1 for the experience period. Show your
work.
COURSE 8: Fall 2005 -8- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
8. (7 points) You are the consulting actuary for ACME, Inc. They are interested in offering
a Patient Directed Healthcare Benefit (PDHB) plan with the following structure:
Option 1
%26#8226; Multi-plan option plus Flexible Spending Account (FSA),
%26#8226; Employer provides core contribution, offers multiple health plan choices,
and sets menu.
Option 2
%26#8226; High Deductible Plan plus FSA plus Personal Health Account (PHA),
%26#8226; Employer provides core contribution, access to multiple high deductible
plans, and segregated PHA’s.
(a) Describe factors that are making consumerism a significant trend.
(b) Compare and contrast the key dimensions of PDHB’s as they relate to the two
options ACME is considering.
(c) Describe the healthcare challenges that can be addressed by PDHB’s with respect
to:
i. Employees
ii. Employers
COURSE 8: Fall 2005 -9- GO TO NEXT PAGE
Health, Group Life %26amp; Managed Care
9. (5 points) You are the pricing actuary for Enamel Insurance Company (EIC). EIC is
interested in adding a dental product to its portfolio and has asked you to prepare a report
to senior management.
(a) Describe ways to control dental claims costs.
(b) Describe the underwriting and rating parameters used for dental insurance.
COURSE 8: Fall 2005 -10- STOP
Health, Group Life %26amp; Managed Care
10. (3 points) You are the Valuation Actuary for Belt and Suspenders Health Insurance
Company. Your company offers a variety of health products that may require a variety of
methods for determining claim liabilities.
(a) Describe considerations which might influence the level of conservatism targeted
for a given block of business.
(b) Describe approaches to introducing conservatism into each of the common
methods used to compute claim liabilities.
COURSE 8: Fall 2005 - 11 - GO TO NEXT PAGE
Managed Care Segment
**BEGINNING OF EXAMINATION**
MANAGED CARE SEGMENT
Beginning with Question 11
11. (4 points) Regarding claims practices for short term disability (STD) coverages:
(a) Describe the tools available to challenge questionable STD claims.
(b) Discuss methods, including the pros and cons for measuring overall STD claims
levels.
(c) Describe the sources of information available to a claims examiner regarding STD
claims.
COURSE 8: Fall 2005 - 12 - GO TO NEXT PAGE
Managed Care Segment
12. (4 points) You are an actuary responsible for developing your company’s financial
forecast models. Recently your company has improved access and quality of data. The
Chief Actuary is now encouraging you to incorporate additional situations in forecast
modeling.
(a) (3 points) Discuss basic principles for designing forecast models.
(b) (1 point) Outline ways in which forecast modeling can influence company
actions to help achieve business objectives.
COURSE 8: Fall 2005 - 13 - GO TO NEXT PAGE
Managed Care Segment
13. (8 points) You are the chief actuary for ABC Insurance Company. You are considering
purchasing an individual insurance block of business but are concerned about ABC’s
ability to administer such business.
(a) Discuss the steps an agent goes through in selling and servicing individual health
insurance policies.
(b) Describe considerations in plan design, pricing, and distribution channels.
(c) Describe the typical underwriting considerati[1] [2] [3] 下一页 |
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