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Rule 20:06:13:0A Medicare Supplement Refund Calculation Forms. DEPARTMENT OF REVENUE AND REGULATION

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 


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