{"data":{"id":"us-va/14vac5-170-220-1","jurisdiction":"us-va","citation":"14VAC5-170-220:1","heading":"APPENDIX A. MEDICARE SUPPLEMENT REFUND CALCULATION FORM","body":"APPENDIX A\n\n8/05\n\nAPPENDIX A\n\nMEDICARE SUPPLEMENT REFUND CALCULATION FORM\n\nFOR CALENDAR YEAR _______\n\nTYPE1 ______________________________\n\nSMSBP2 ____________________________\n\nFOR THE STATE OF ___________________________________________________________\n\nCompany Name   _______________________________________________________________\n\nNAIC Group Code ____________________\n\nNAIC Company Code __________________\n\nAddress _____________________________________________________________________\n\nPerson Completing This Exhibit   ___________________________________________________\n\nTitle _______________________________\n\nTelephone Number ____________________\n\nline\n\n(a)\n\nEarned Premium3\n\n(b)\n\nIncurred Claims4\n\n1. Current Year's Experience\n\na. Total (all policy years)\n\nb. Current year's issues5\n\nc. Net (for reporting purposes 1a - 1b)\n\n____________\n\n___________\n\n2. Past Year's Experience (All Policy Years)\n\n____________\n\n___________\n\n3. Total Experience (Net Current Year + Past Year's   Experience)\n\n____________\n\n___________\n\n4. Refund last year (Excluding Interest)\n\n5. Previous Since Inception (Excluding Interest)\n\n____________\n\n___________\n\n6. Refunds Since Inception (Excluding Interest)\n\n7. Benchmark Ratio Since Inception (See Worksheet for Ratio   1)\n\n8. Experienced Ratio Since Inception\n\nTotal Actual Incurred Claims (line 3, col b) = Ratio 2\n\nTotal Earned Prem. (line 3, col a) - Refunds Since Inception   (line 6)\n\n9. Life Years Exposed Since   Inception ___________________________________________\n\nIf the Experienced Ratio is less than the Benchmark Ratio,   and there are more than 500 life years exposure, then proceed to calculation   of refund.\n\n10. Tolerance Permitted (obtained   from credibility table) _____________________________\n\nMedicare Supplement Credibility Table\n\nLife Years Exposed\n\nSince Inception\n\nTolerance\n\n10,000 +\n\n0.0%\n\n5,000 - 9,999\n\n5.0%\n\n2,500 - 4,999\n\n7.5%\n\n1,000 - 2,499\n\n10.0%\n\n500 - 999\n\n15.0%\n\nIf less than 500, no credibility\n\n11. Adjustment to Incurred Claims   for Credibility _________________________\n\nRatio 3 = Ratio 2 + Tolerance\n\nIf Ratio 3 is more than Benchmark Ratio (Ratio 1), a refund   or credit to premium is not required.\n\nIf Ratio 3 is less than the Benchmark Ratio, then proceed.\n\n12. Adjusted Incurred Claims =   ___________________________________\n\n[Total Earned Premiums (line 3, col a) - Refunds Since   Inception (line 6)] x Ratio 3 (line 11)\n\n13. Refund = Total Earned Premiums   (line 3, col a) - Refunds Since Inception (line 6) - Adjusted Incurred Claims   (line 12)\n\nBenchmark Ratio (Ratio 1)__________________________\n\nIf 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.\n\nIf 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.\n\n1Individual, Group, Individual Medicare Select,   or Group Medicare Select Only.\n\n2SMSBP = Standardized Medicare Supplement Benefit   Plan - Use P for prestandardized plans.\n\n3Includes modal loadings and fees charged\n\n4Excludes Active Life Reserves\n\n5This is to be used as Issue Year Earned Premium for   Year 1 of next year's Worksheet for Calculation of Benchmark Ratios\n\nI certify that the above information and calculations are true and accurate to the best of my knowledge and belief.\n\nSignature\n\nName - Please Type\n\nTitle\n\nDate\n\n8/05\n\nAPPENDIX A\n\nREPORTING FORM FOR THE CALCULATION OF\n\nBENCHMARK RATIO SINCE INCEPTION\n\nFOR GROUP POLICIES\n\nFOR CALENDAR YEAR ________\n\nTYPE(1) ____________________________\n\nSMSBP(2) _____________________________\n\nFOR THE STATE OF   ___________________________________________________________\n\nCompany Name   _______________________________________________________________\n\nNAIC Group Code ____________________\n\nNAIC Company Code ____________________\n\nAddress   _____________________________________________________________________\n\nPerson Completing This Exhibit   ___________________________________________________\n\nTitle _______________________________\n\nTelephone Number ______________________\n\n(a)(3)\n\n(b)(4)\n\n(c)\n\n(d)\n\n(e)\n\n(f)\n\n(g)\n\n(h)\n\n(i)\n\n(j)\n\n(o)(5)\n\nYear\n\nEarned Premium\n\nFactor\n\n(b) x (c)\n\nCumulative Loss Ratio\n\n(d) x (e)\n\nFactor\n\n(b) x (g)\n\nCumulative Loss Ratio\n\n(h) x (i)\n\nPolicy Year Loss Ratio\n\n1\n\n2.770\n\n0.507\n\n0.000\n\n0.000\n\n0.46\n\n2\n\n4.175\n\n0.567\n\n0.000\n\n0.000\n\n0.63\n\n3\n\n4.175\n\n0.567\n\n1.194\n\n0.759\n\n0.75\n\n4\n\n4.175\n\n0.567\n\n2.245\n\n0.771\n\n0.77\n\n5\n\n4.175\n\n0.567\n\n3.170\n\n0.782\n\n0.8\n\n6\n\n4.175\n\n0.567\n\n3.998\n\n0.792\n\n0.82\n\n7\n\n4.175\n\n0.567\n\n4.754\n\n0.802\n\n0.84\n\n8\n\n4.175\n\n0.567\n\n5.445\n\n0.811\n\n0.87\n\n9\n\n4.175\n\n0.567\n\n6.075\n\n0.818\n\n0.88\n\n10\n\n4.175\n\n0.567\n\n6.650\n\n0.824\n\n0.88\n\n11\n\n4.175\n\n0.567\n\n7.176\n\n0.828\n\n0.88\n\n12\n\n4.175\n\n0.567\n\n7.655\n\n0.831\n\n0.88\n\n13\n\n4.175\n\n0.567\n\n8.093\n\n0.834\n\n0.89\n\n14\n\n4.175\n\n0.567\n\n8.493\n\n0.837\n\n0.89\n\n15+(6)\n\n4.175\n\n0.567\n\n8.684\n\n0.838\n\n0.89\n\nTotal:\n\n(k):___\n\n(l):___\n\n(m):__\n\n(n):___\n\nBenchmark Ratio Since Inception: (l + n)/(k + m):\n\n(1): Individual, Group, Individual Medicare Select, or Group Medicare Select Only.\n\n(2): \"SMSBP\" = Standardized Medicare Supplement Benefit Plan - Use \"P\" for pre-standardized plans.\n\n(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.)\n\n(4): For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.\n\n(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.\n\n(6): To include the earned premium for all years prior to as well as the 15th year prior to the current year.\n\n8/05\n\nAPPENDIX A\n\nREPORTING FORM FOR THE CALCULATION OF\n\nBENCHMARK RATIO SINCE INCEPTION\n\nFOR INDIVIDUAL POLICIES\n\nFOR CALENDAR YEAR ___________\n\nTYPE(1) ____________________________\n\nSMSBP(2) _____________________________\n\nFOR THE STATE OF   ___________________________________________________________\n\nCompany Name   _______________________________________________________________\n\nNAIC Group Code ____________________\n\nNAIC Company Code ____________________\n\nAddress   _____________________________________________________________________\n\nPerson Completing This Exhibit   ___________________________________________________\n\nTitle _______________________________\n\nTelephone Number ______________________\n\n(a)(3)\n\n(b)(4)\n\n(c)\n\n(d)\n\n(e)\n\n(f)\n\n(g)\n\n(h)\n\n(i)\n\n(j)\n\n(o)(5)\n\nYear\n\nEarned Premium\n\nFactor\n\n(b) x (c)\n\nCumulative Loss Ratio\n\n(d) x (e)\n\nFactor\n\n(b) x (g)\n\nCumulative Loss Ratio\n\n(h) x (i)\n\nPolicy Year Loss Ratio\n\n1\n\n2.770\n\n0.442\n\n0.000\n\n0.000\n\n0.4\n\n2\n\n4.175\n\n0.493\n\n0.000\n\n0.000\n\n0.55\n\n3\n\n4.175\n\n0.493\n\n1.194\n\n0.659\n\n0.65\n\n4\n\n4.175\n\n0.493\n\n2.245\n\n0.669\n\n0.67\n\n5\n\n4.175\n\n0.493\n\n3.170\n\n0.678\n\n0.69\n\n6\n\n4.175\n\n0.493\n\n3.998\n\n0.686\n\n0.71\n\n7\n\n4.175\n\n0.493\n\n4.754\n\n0.695\n\n0.73\n\n8\n\n4.175\n\n0.493\n\n5.445\n\n0.702\n\n0.75\n\n9\n\n4.175\n\n0.493\n\n6.075\n\n0.708\n\n0.76\n\n10\n\n4.175\n\n0.493\n\n6.650\n\n0.713\n\n0.76\n\n11\n\n4.175\n\n0.493\n\n7.176\n\n0.717\n\n0.76\n\n12\n\n4.175\n\n0.493\n\n7.655\n\n0.720\n\n0.77\n\n13\n\n4.175\n\n0.493\n\n8.093\n\n0.723\n\n0.77\n\n14\n\n4.175\n\n0.493\n\n8.493\n\n0.725\n\n0.77\n\n15+(6)\n\n4.175\n\n0.493\n\n8.684\n\n0.725\n\n0.77\n\nTotal:\n\n(k):___\n\n(l):___\n\n(m):___\n\n(n):___\n\nBenchmark Ratio Since Inception: (l + n)/(k + m):\n\n(1): Individual, Group, Individual Medicare Select, or Group Medicare Select Only.\n\n(2): \"SMSBP\" = Standardized Medicare Supplement Benefit Plan - Use \"P\" for pre-standardized plans.\n\n(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.)\n\n(4): For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.\n\n(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.\n\n(6): To include the earned premium for all years prior to as well as the 15th year prior to the current year.","path":["Title 14. Insurance","Agency 5. State Corporation Commission, Bureau of Insurance","Chapter 170. Rules Governing Minimum Standards for Medicare Supplement Policies"],"source_url":"https://law.lis.virginia.gov/admincode/title14/agency5/chapter170/section220:1/","current_through":"2026 Regular Session (effective July 1, 2026)","vintage":"","retrieved_at":"2026-09-14T04:51:53Z","sha256":"720bf481e7ba7c842d99cbc7714c4a123216fe32b11bd3cd75acf1fa0333a082","source_id":"us-va-vac","stale":false,"prev":"us-va/14vac5-170-220","next":"us-va/14vac5-170-220-2"},"notice":"GroundRules: Original legal text. Not legal advice."}