Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Appendix 031-275-A - MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR

Current through 2024-29, July 17, 2024
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%
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_________________
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 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____________________
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
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____________________
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
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.