Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-220:1 - APPENDIX A. MEDICARE SUPPLEMENT REFUND CALCULATION FORM

Current through Register Vol. 40, No. 24, July 15, 2024
8/05
APPENDIX A 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 This 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's Experience)
____________
___________
4. Refund 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
Total Actual Incurred Claims (line 3, col b)
						  = Ratio 2
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
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 the 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 and/or credit against
						  premiums to be used must be attached to this form.
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 and/or credit against premiums to be
						  used must be attached to this form.
1Individual,
						  Group, Individual Medicare Select, or Group Medicare Select Only.
2SMSBP =
						  Standardized Medicare Supplement Benefit Plan - Use P for prestandardized
						  plans.
3Includes modal
						  loadings and fees charged
4Excludes Active
						  Life Reserves
5This is to be
						  used as Issue Year Earned Premium for Year 1 of next year's Worksheet for
						  Calculation of Benchmark Ratios
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
Date
8/05
APPENDIX A
REPORTING FORM FOR THE CALCULATION OF
						  BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES FOR CALENDAR YEAR ________
TYPE(1)
						  ____________________________
SMSBP(2)
						  _____________________________
FOR THE STATE OF
						  ___________________________________________________________
Company Name
						  _______________________________________________________________
NAIC Group Code ____________________
NAIC Company Code ____________________
Address
						  _____________________________________________________________________
Person Completing This 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
0.8
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):\s Individual, Group, Individual Medicare
				Select, or Group Medicare Select Only.
(2):\s "SMSBP" = Standardized Medicare
				Supplement Benefit Plan - Use "P" for pre-standardized plans.
(3):\s 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):\s For the calendar year on the appropriate
				line in column (a), the premium earned during that year for policies issued in
				that year.
(5):\s 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):\s To include the earned
				premium for all years prior to as well as the 15th year prior to the current
				year.
8/05
APPENDIX A
REPORTING FORM FOR THE CALCULATION OF
						  BENCHMARK RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES FOR CALENDAR YEAR
						  ___________
TYPE(1)
						  ____________________________
SMSBP(2)
						  _____________________________
FOR THE STATE OF
						  ___________________________________________________________
Company Name
						  _______________________________________________________________
NAIC Group Code ____________________
NAIC Company Code ____________________
Address
						  _____________________________________________________________________
Person Completing This 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
0.4
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):\s Individual, Group, Individual Medicare
				Select, or Group Medicare Select Only.
(2):\s "SMSBP" = Standardized Medicare
				Supplement Benefit Plan - Use "P" for pre-standardized plans.
(3):\s 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):\s For the calendar year on the appropriate
				line in column (a), the premium earned during that year for policies issued in
				that year.
(5):\s 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):\s To include the earned
				premium for all years prior to as well as the 15th year prior to the current
				year.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.