C.M.R. 02, 031, ch. 275, app 031-275-A

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Current through 2025-03, January 15, 2025

Appendix 031-275-A - MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR

TYPE¹______________________________________

SMSBP²____________________________________

For the State of_______________________________ Company Name______________________________

NAIC Group Code_____________________________ NAIC Company Code_________________________

Address_____________________________________ Person Completing Exhibit____________________

Title________________________________________ Telephone Number___________________________

Line	(a) Earned Premium³	(b) Incurred Claims⁴
1.	Current Year's Experience
a. Total (all policy years)
b. Current year's issues⁵
c. Net (for reporting purposes = 1a-1b
2.	Past Years' Experience (all policy years)
3.	Total Experience (Net Current Year + Past Year)
4.	Refunds Last Year (Excluding Interest)
5.	Previous Since Inception (Excluding Interest)
6.	Refunds Since Inception (Excluding Interest)
7.	Benchmark Ratio Since Inception (see worksheet for Ratio 1)
8.	Experienced Ratio Since Inception (Ratio 2) Total Actual Incurred Claims (line 3, col. b)/ Total Earned Prem. (line 3, col. a)-Refunds Since Inception (line 6)
9.	Life Years Exposed Since Inception If the Experienced Ratio is less than the Benchmark Ratio, and there are more than 500 life years exposure, then proceed to calculation of refund.
10.	Tolerance Permitted (obtained from credibility table)

Medicare Supplement Credibility Table

Life Years Exposed
Since Inception	Tolerance
10,000 +	0.0%
5,000 -9,999	5.0%
2,500 -4,999	7.5%
1,000 -2,499	10.0%
500 - 999	15.0%
If less than 500, no credibility.

¹ Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

² "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans.

³ Includes Modal Loadings and Fees Charged

⁴ Excludes Active Life Reserves

⁵ This is to be used as "Issue Year Earned Premium" for Year 1 of next year's "Worksheet for Calculation of Benchmark Ratios"

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR_________________

TYPE¹______________________________________

SMSBP²____________________________________

For the State of_______________________________ Company Name______________________________

NAIC Group Code_____________________________ NAIC Company Code_________________________

Address_____________________________________ Person Completing Exhibit____________________

Title________________________________________ Telephone Number___________________________

11.	Adjustment to Incurred Claims for Credibility
Ratio 3 = Ratio 2 + Tolerance

If Ratio 3 is more than Benchmark Ratio (Ratio 1), a refund or credit to premium is not required.

If Ratio 3 is less than the Benchmark Ratio, then proceed.

12.	Adjusted Incurred Claims
[Total Earned Premiums (line 3, col. a)-Refunds Since Inception (line 6)] x Ratio 3 (line 11)
13.	Refund =
Total Earned Premiums (line 3, col. a)-Refunds Since Inception (line 6) -[Adjusted Incurred Claims (line 12)/Benchmark Ratio (Ratio 1)]

If the amount on line 13 is less than .005 times the annualized premium in force as of December 31 of the reporting year, then no refund is made. Otherwise, the amount on line 13 is to be refunded or credited, and a description of the refund or credit against premiums to be used must be attached to this form.

I certify that the above information and calculations are true and accurate to the best of my knowledge and belief.

_______________________________________

Signature

_______________________________________

Name - Please Type

_______________________________________

Title - Please Type

_______________________________________

Date

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES FOR CALENDAR YEAR____________________

TYPE¹_____________________________ SMSBP²___________________________

For the State of__________________ Company Name_____________________

NAIC Group Code___________________ NAIC Company Code________________

Address___________________________ Person Completing Exhibit________

Title_____________________________ Telephone Number_________________

(a)³	(b)⁴	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)⁵
Year	Earned Premium	Factor	(b)x(c)	Cumulative Loss Ratio	(d)x(e)	Factor	(b)x(g)	Cumulative Loss Ratio	(h)x(i)	Policy Year Loss Ratio
1	2.770	0.507	0.000	0.000	0.46
2	4.175	0.567	0.000	0.000	0.63
3	4.175	0.567	1.194	0.759	0.75
4	4.175	0.567	2.245	0.771	0.77
5	4.175	0.567	3.170	0.782	0.80
6	4.175	0.567	3.998	0.792	0.82
7	4.175	0.567	4.754	0.802	0.84
8	4.175	0.567	5.445	0.811	0.87
9	4.175	0.567	6.075	0.818	0.88
10	4.175	0.567	6.650	0.824	0.88
11	4.175	0.567	7.176	0.828	0.88
12	4.175	0.567	7.655	0.831	0.88
13	4.175	0.567	8.093	0.834	0.89
14	4.175	0.567	8.493	0.837	0.89
15	4.175	0.567	8.684	0.838	0.89
Total:	(k):	(l):	(m):	(n):

Benchmark Ratio Since Inception: (l + n)/(k + m): __________

¹ Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

² "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans

³ Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

⁴ For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

⁵ These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, which result in the cumulative loss ratios displayed on this worksheet. They are shown here for informational purposes only.

⁶ To include the earned premium for all years prior to as well as the 15^th year prior to the current year.

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES FOR CALENDAR YEAR____________________

TYPE¹_____________________________ SMSBP²___________________________

For the State of__________________ Company Name_____________________

NAIC Group Code___________________ NAIC Company Code________________

Address___________________________ Person Completing Exhibit________

Title_____________________________ Telephone Number_________________

(a)³	(b)⁴	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)⁵
Year	Earned Premium	Factor	(b)x(c)	Cumulative Loss Ratio	(d)x(e)	Factor	(b)x(g)	Cumulative Loss Ratio	(h)x(i)	Policy Year Loss Ratio
1	2.770	0.442	0.000	0.000	0.40
2	4.175	0.493	0.000	0.000	0.55
3	4.175	0.493	1.194	0.659	0.65
4	4.175	0.493	2.245	0.669	0.67
5	4.175	0.493	3.170	0.678	0.69
6	4.175	0.493	3.998	0.686	0.71
7	4.175	0.493	4.754	0.695	0.73
8	4.175	0.493	5.445	0.702	0.75
9	4.175	0.493	6.075	0.708	0.76
10	4.175	0.493	6.650	0.713	0.76
11	4.175	0.493	7.176	0.717	0.76
12	4.175	0.493	7.655	0.720	0.77
13	4.175	0.493	8.093	0.723	0.77
14	4.175	0.493	8.493	0.725	0.77
15	4.175	0.493	8.684	0.725	0.77
Total:	(k):	(l):	(m):	(n):

Benchmark Ratio Since Inception: (l + n)/(k + m): __________

¹ Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

² "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans

³ Year 1 is the current calendar year - 1. Year 2 is the current calendar year - 2 (etc.) (Example: If the current year is 1991, then: Year 1 is 1990; Year 2 is 1989, etc.)

⁴ For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

⁶ To include the earned premium for all years prior to as well as the 15^th year prior to the current year.

C.M.R. 02, 031, ch. 275, app 031-275-A