精算师

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Subject: Quality Dental Coverage with 3 Months at No Charge

Affordable Dental Coverage

???save up to 60% on all your dental needs

???choose from 15 of the finest nationwide and regional plans

???pay premiums, submit claims, get the latest information, all on your desktop!

(a) List the general types of delivery systems for dental plans and their major

features.

(b) Outline plan provisions and claim practices that dental insurers can use to

limit cost and anti-selection.

(c) Describe challenges that e-commerce companies must overcome to be

successful.

COURSE 8: Fall 2003 - 11 - GO TO NEXT PAGE

Managed Care Segment

Afternoon Session

Questions 15 - 18 pertain to the case study

15. (4 points) The Bedford Group is exploring alternatives to acute inpatient care. A study

by Bedford’s Medical Director indicates the MCO might benefit from a program to

encourage patients with conditions requiring less intensive treatment to be moved from

acute care facilities to a Skilled Nursing Facility (SNF). The initiative would transfer

acute care patients to the SNF at Hospital ID1 and is expected to result in the following

changes:

Reduction in

Medical Acute Days

Reduction in

Surgical Acute Days

Hosp ID1 1.0% 0.5%

Hosp ID2 2.0% 2.0%

Hosp ID3 1.5% 1.0%

(a) Assuming the above reductions are realized, and based on Table MC-2, calculate

the expected change in medical, surgical and SNF days/1000 and the change in

medical/surgical length of stay in 2002 for the MCO. Show your work.

(b) Describe behavioral health channeling mechanisms available to direct individuals

to the appropriate type of care.

COURSE 8: Fall 2003 - 12 - GO TO NEXT PAGE

Managed Care Segment

Afternoon Session

Questions 15 - 18 pertain to the case study

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

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