Connecticut Administrative Code › Title 38a - Insurance Department › 495a - Medicare Supplement Insurance › Appendix A

Current through July 10, 2024
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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 Years'
				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
----------------------
Tot. 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 charges.
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"
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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 =
(Tot. 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 the 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.
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
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(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): __________
1Individual, Group, Individual
				Medicare Select, or Group Medicare Select Only.
2"SMSBP" = Standardized Medicare
				Supplement Benefit Plan. Use "P" for pre-standardized plans.
3Year 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.)
4For the calendar year on the
				appropriate line in column (a), the premium earned during that year for
				policies issued in that year.
5These 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.
6To include the earned premium for
				all years prior to as well as the 15th year prior to the current year.
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				here to view image.
(a)3
(b)4
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(o)5
Year
Earned
Premium
Factor
(b)x(c)
Cumul ative 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): __________
1Individual, Group, Individual
				Medicare Select, or Group Medicare Select Only.
2"SMSBP" = Standardized Medicare
				Supplement Benefit Plan. Use "P" for pre-standardized plans.
3Year 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.)
				4For the calendar year on the appropriate line in
				column (a), the premium earned during that year for policies issued in that
				year.
5These 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.
6To include the earned premium for
				all years prior to as well as the 15th year prior to the current year.