GroundRules
14VAC5-170-220:1: APPENDIX A. MEDICARE SUPPLEMENT REFUND CALCULATION FORM
Where this section sits in the code
- Title 14. Insurance
- Agency 5. State Corporation Commission, Bureau of Insurance
- Chapter 170. Rules Governing Minimum Standards for Medicare Supplement Policies
APPENDIX A
8/05
APPENDIX 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 This 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 Year's Experience (All Policy Years)
____________
___________
3. Total Experience (Net Current Year + Past Year's Experience)
____________
___________
4. Refund 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 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
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 the 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.
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.
1Individual, Group, Individual Medicare Select, or Group Medicare Select Only.
2SMSBP = Standardized Medicare Supplement Benefit Plan - Use P for prestandardized plans.
3Includes modal loadings and fees charged
4Excludes Active Life Reserves
5This 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
Date
8/05
APPENDIX A
REPORTING FORM FOR THE CALCULATION OF
BENCHMARK RATIO SINCE INCEPTION
FOR GROUP POLICIES
FOR CALENDAR YEAR ________
TYPE(1) ____________________________
SMSBP(2) _____________________________
FOR THE STATE OF ___________________________________________________________
Company Name _______________________________________________________________
NAIC Group Code ____________________
NAIC Company Code ____________________
Address _____________________________________________________________________
Person Completing This 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
0.8
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+(6)
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 15th year prior to the current year.
8/05
APPENDIX A
REPORTING FORM FOR THE CALCULATION OF
BENCHMARK RATIO SINCE INCEPTION
FOR INDIVIDUAL POLICIES
FOR CALENDAR YEAR ___________
TYPE(1) ____________________________
SMSBP(2) _____________________________
FOR THE STATE OF ___________________________________________________________
Company Name _______________________________________________________________
NAIC Group Code ____________________
NAIC Company Code ____________________
Address _____________________________________________________________________
Person Completing This 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
0.4
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+(6)
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.
(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 15th year prior to the current year.
Collected 2026-09-14T04:51:53Z. Source file · JSON