Hawaii Administrative Rules › Title 16 - DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS › Chapter 12 - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Exhibit E - Reporting Form for The Calculation of Benchmark Ratio since Inception for Group Policies for Calendar Year

Current through June, 2024
REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO
				SINCE INCEPTION FOR GROUP POLICIES FOR CALENDAR YEAR___________
TYPE1_____________________________________________
				SMSBP2________________________________________________
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
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
0.80
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):
(I):
(m):
(n):
Benchmark Ratio Since Inception: (I + 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____________
TYPE1_____________________________________________
				SMSBP2________________________________________________
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
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
0.40
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):
(I):
(m):
(n):
Benchmark Ratio Since Inception: (I + 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.
The amended
				version of this section by
				Hawaii
				Administrative Rules Listing of Filings, 2019-01, July, eff.
				8/1/2019 is not yet
				available.