Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Exhibit D › Appendix A - Medicare Supplement Refund Calculation Form for Calendar Year

Current through June, 2024
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 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 Years' Experience (all policy years)
3.
Total Experience (Net Current Year + Past Year)
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
(Ratio
							 2)
Total Actual Incurred Claims (line 3, col.
							 b)
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%
It 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 prestandardized plans.
3 Includes Modal Loadings and Fees
				  Charged.
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".
Medicare Supplement Insurance Regulation
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 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
				  Patio, 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 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
The amended
				  version of this section by
				  Hawaii
				  Administrative Rules Listing of Filings, 2019-01, July, eff.
				  8/1/2019 is not yet
				  available.