Administrative Rules of Montana › Department 6 - STATE AUDITOR › Chapter 6.6 - INSURANCE DEPARTMENT › Subchapter 6.6.5 - Medicare Supplements › Rule 6.6.524 - APPENDIX A - MEDICARE SUPPLEMENT REFUND CALCULATION FORM

Current through Register Vol. 13, July 5, 2024
(1) This is the appendix referred to in ARM
				  6.6.508(2) and
				  (3).
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 Year's 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 Premium (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.
Individual, Group, Individual Medicare Select, or Group
				  Medicare Select Only. "SMSBP" = Standardized Medicare Supplement Benefit Plan -
				  Use "P" for prestandardized plans. Includes Modal Loadings and Fees Charged
				  Excludes Active Life Reserves This is to be used as "Issue Year Earned Premium"
				  for Year 1 of next year's "Worksheet for Calculation of Benchmark
				  Ratios"
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 Premium (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 ____________
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):
(l):
(m):
(n):
Benchmark Ratio Since Inception (1 + 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):
(l):
(m):
(n):
Benchmark Ratio Since Inception (1 + 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.
33-22-904 and
					 33-22-905, MCA; IMP,
					 33-15-303,
					 33-22-901,
					 33-22-902,
					 33-22-903,
					 33-22-904,
					 33-22-905,
					 33-22-906,
					 33-22-907,
					 33-22-908,
					 33-22-909,
					 33-22-910,
					 33-22-911,
					 33-22-921,
					 33-22-922,
					 33-22-923, and
					 33-22-924,
					 MCA;