Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-8 - MEDICARE SUPPLEMENT INSURANCE › Appendix (120-2-8) A - MEDICARE SUPPLEMENT REFUND CALCULATION FORM

Current through Rules and Regulations filed through June 27, 2024
FOR CALENDAR YEAR_________________
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%
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 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 REFUND CALCULATION FORM
FOR CALENDAR YEAR_________________
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 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 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
FOR CALENDAR YEAR____________________
For the State of Company Name
NAIC Group Code NAIC Company Code
Address Person Completing Exhibit
Title Telephone Number
(a)³
(b)4
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(o)5
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+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.
REPORTING FORM FOR THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES
FOR CALENDAR YEAR____________________
For the State of Company Name
NAIC Group Code NAIC Company Code
Address Person Completing Exhibit
Title Telephone Number
(a)³
(b)4
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(o)5
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+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.