DEPARTMENT
OF LABOR AND REGULATION
DIVISION
OF INSURANCE
MEDICARE
SUPPLEMENT REFUND CALCULATION FORMS
Chapter
20:06:13
APPENDIX
A
SEE:
§ 20:06:13:21.01
Source: 18 SDR 225, effective July 17, 1992; 31 SDR 214, effective July 6, 2005; 39 SDR 10, effective August 1, 2012.
APPENDIX A
MEDICARE
SUPPLEMENT REFUND CALCULATION FORM
FOR
CALENDAR YEAR_________________
TYPE
(u) ___________________________ SMSBP (w)
_________________________
For
the State of ______________ Company Name ______________________________
NAIC
Group Code ___________ NAIC Company Code _________________________
Address
________________________________________________________________
Person
Completing This Exhibit _____________________________________________
Title
____________________________________ Telephone Number_______________
|
Line
|
|
(a)
Earned
Premium (x)
|
(b)
Incurred
Claims (y)
|
|
1.
|
Current Year's Experience
|
|
|
|
|
a. Total (all policy years)
|
|
|
|
|
b. Current year's issues (z)
c. Net (for reporting purposes =
1a - 1b)
|
___________
|
____________
|
|
2.
|
Past Years' Experience (all policy
years)
|
___________
|
____________
|
|
3.
|
Total Experience
(Net Current Year + Past Year's
Experience)
|
___________
|
____________
|
|
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
Total Actual Incurred Claims (line
3, col. b) = Ratio 2
----------------------------------------------------
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 REFUND CALCULATION FORM
FOR
CALENDAR YEAR_________________
TYPE
(u) ___________________________ SMSBP (w)
_________________________
For
the State of ______________ Company Name ______________________________
NAIC
Group Code ___________ NAIC Company Code _________________________
Address
________________________________________________________________
Person
Completing This 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 and/or credit
against premiums to be used must be attached to this form.
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.
MEDICARE
SUPPLEMENT REFUND CALCULATION FORM
FOR
CALENDAR YEAR_________________
TYPE
(u) ___________________________ SMSBP (w)
_________________________
For
the State of ______________ Company Name ______________________________
NAIC
Group Code ___________ NAIC Company Code _________________________
Address
________________________________________________________________
Person
Completing This Exhibit _____________________________________________
Title
____________________________________ Telephone Number_______________
(u) Individual,
Group, Individual Medicare Select, or Group Medicare Select Only.
(w)
"SMSBP" = Standardized Medicare Supplement Benefit Plan - Use
"P" for pre-standardized plans.
(x) Includes Modal
Loadings and Fees Charged
(y) Excludes
Active Life Reserves
(z)
This is to be used as "Issue Year Earned Premium" for Year 1 of next
year's "Worksheet for Calculation of Benchmark Ratios."
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____________________
TYPE
(q) ____________________ SMSBP (p) _____________________
FOR
THE STATE OF __________ Company Name _________________
NAIC
Group Code ______________ NAIC Company Code ___________
Address
____________________________________________________
Person
Completing This Exhibit _________________________________
Title
___________________________ Telephone Number ____________
|
(a)
|
(b)
|
(c)
|
(d)
|
(e)
|
(f)
|
(g)
|
(h)
|
(i)
|
(j)
|
(o)
|
|
|
Earned
|
|
|
Cumulative
|
|
|
|
Cumulative
|
|
Policy
Year
|
|
Year
|
Premium
|
Factor
|
(b)
x (c)
|
Loss
Ratio
|
(d)
x (e)
|
Factor
|
(b)
x (g)
|
Loss
Ratio
|
(h)
x (i)
|
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: (1 + n) /
(k + m):
(a): Year 1 is the current
calendar year - 1 (b): For the calendar
year on the appropriate line in column (a),
Year 2 is the current
calendar year - 2 (etc.) the premium earned
during that year for policies issued in
(Example: If the current
year is 1991, then: that year.
Year 1 is 1990; Year 2 is
1989, etc.).
Year 15+ is the earned
premium for all years prior
to as well as the 15th
year prior to the current year.
(o): These loss ratios are not
explicitly used in computing the (p): "SMSBP" = Standardized Medicare
Supplement Benefit Plan.
benchmark loss ratios.
They are the loss ratios, on
a policy year basis,
which result in the cumulative (q): Individual Group,
Individual Medicare Select, or Group Medicare
loss ratios displayed on
this worksheet. They are shown Select Only.
here for informational
purposes only.
REPORTING
FORM FOR THE CALCULATION OF BENCHMARK
RATIO
SINCE INCEPTION FOR INDIVIDUAL POLICIES
FOR
CALENDAR YEAR____________________
TYPE
(q) ____________________ SMSBP (p) _____________________
FOR
THE STATE OF __________ Company Name _________________
NAIC
Group Code ______________ NAIC Company Code ___________
Address
____________________________________________________
Person
Completing This Exhibit _________________________________
Title
___________________________ Telephone Number ____________
|
(a)
|
(b)
|
(c)
|
(d)
|
(e)
|
(f)
|
(g)
|
(h)
|
(i)
|
(j)
|
(o)
|
|
|
Earned
|
|
|
Cumulative
|
|
|
|
Cumulative
|
|
Policy
Year
|
|
Year
|
Premium
|
Factor
|
(b)
x (c)
|
Loss
Ratio
|
(d)
x (e)
|
Factor
|
(b)
x (g)
|
Loss
Ratio
|
(h)
x (i)
|
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):
(a): Year 1 is the current
calendar year - 1 (b): For the calendar
year on the appropriate line in column (a),
Year 2 is the current
calendar year - 2 (etc.) the premium
earned during that year for policies issued in that
(Example: If the current
year is 1991, then: year.
Year 1 is 1990; Year 2 is
1989, etc.).
Year 15+ is the earned
premium for all years prior
to as well as the 15th
year prior to the current year.
(o): These loss ratios are not
explicitly used in computing the ( p): "SMSBP" = Standardized
Medicare Supplement Benefit Plan.
benchmark loss ratios.
They are the loss ratios, on
a policy year basis,
which result in the cumulative (q): Individual Group,
Individual Medicare Select, or Group Medicare
loss ratios displayed on
this worksheet. They are shown Select Only.
here for informational
purposes only.