Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-66 - Washington medicare supplement insurance regulation › Section 284-66-232 - Form for medicare supplement refund calculation

Current through Register Vol. 24-14, July 15, 2024
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR
TYPE
SMSBP(w)
For the State of
Washington Policy or Certificate Form No(s).
Company Name
NAIC Group Code
NAIC Company Code
Person Completing This Exhibit
Title
Telephone Number
Line
(a)
Earned
Premium (x)
(b)
Incurred Claims (y)
1. Current Year's Experience
a. Total (all policy years)
b. Current year's issues (z)
c. Net (for reporting purposes = 1a - 1b)
2. Past Years' Experience
(All Policy Years)
3. Total experience (Net Current Year + Past Years'
							 Experience)
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
Total Actual Incurred Claims (line
							 3, col b)
Total Earned Premium (line 3, col a) - Refunds
							 Since Inception (line 6)
= Ratio 2
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)
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. Adjust 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 and/or credit against premiums to be used must
							 be attached to this form.
Medicare Supplement Credibility Table
Life Year 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
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR
TYPE
SMSBP(w)
For the State of
Washington Policy or Certificate Form No(s).
Company Name
NAIC Group Code
NAIC Company Code
Person Completing This Exhibit
Title
Telephone Number
(w)
"SMSBP" = Standardized Medicare Supplement Benefit
							 Plan
(x)
Includes modal loadings and fees charged.
(y)
Excludes Active Life Reserves.
(z)
This 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
WORKSHEET #1 - INDIVIDUAL
							 POLICIES
REPORTING FORM FOR TIME CALCULATION OF
BENCHMARK RATIO SINCE INCEPTION
FOR INDIVIDUAL POLICIES
FOR CALENDAR YEAR
TYPE
SMSBP (P)
FOR THE STATE OF WASHINGTON
Washington Policy or Certificate Form No.
Company Name
NAIC Group Code
NAIC Company Code
Address
Person Completing This Exhibit
Title
Telephone Number
(a)
Year
(b)
Earned
Premium
(c)
Factor
(d)
(b) x (c)
(e)
Cumulative
Loss Ratio
(f)
(d) x (e)
(g)
Factor
(h)
(b) x (g)
(i)
Cumulative
Loss Ratio
(j)
(h) x (i)
(o)
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+1
4.175
0.493
8.684
0.725
0.77
Total:
(k):
(1):
(m):
(n):
FN for 15+1:
To
				include the earned premium for all years prior to as well as the 15th year
				prior to the current year.
Benchmark Ratio Since Inception: (1 + n) / (k +
							 m):
(a):
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.)
(b):
For the calendar year on the appropriate line in
							 column (a), the premium earned during that year for policies issued in that
							 year.
k =
1 =
m =
n =
Total of Column "d"
Total of Column "f"
Total of Column "h"
Total of Column "j"
(o):
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 ratio displayed on this worksheet.
							 They are shown here for informational purposes only.
(p)
"SMSBP" = Standardized Medicare Supplement Benefit
							 Plan
WORKSHEET #1 - GROUP POLICIES
REPORTING FORM FOR TIME CALCULATION OF
BENCHMARK RATIO SINCE INCEPTION
FOR GROUP POLICIES
FOR CALENDAR YEAR
TYPE
SMSBP (P)
FOR THE STATE OF WASHINGTON
Washington Policy or Certificate Form No.
Company Name
NAIC Group Code
NAIC Company Code
Address
Person Completing This Exhibit
Title
Telephone Number
(a)
Year
(b)
Earned
Premium
(c)
Factor
(d)
(b) x (c)
(e)
Cumulative
Loss Ratio
(f)
(d) x (e)
(g)
Factor
(h)
(b) x (g)
(i)
Cumulative
Loss Ratio
(j)
(h) x (i)
(o)
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+
4.175
0.567
8.684
0.838
0.89
Total:
(k):
(1):
(m):
(n):
FN for 15+:
To include the earned premium for all
				years prior to as well as the 15th year prior to the current year.
Benchmark Ratio Since Inception: (1 + n) / (k +
							 m):
(a):
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.)
(b):
For the calendar year on the appropriate line in
							 column (a), the premium earned during that year for policies issued in that
							 year.
k =
1 =
m =
n =
Total of Column "d"
Total of Column "f"
Total of Column "h"
Total of Column "j"
(o):
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 ratio displayed on this worksheet.
							 They are shown here for informational purposes only.
(p)
"SMSBP" = Standardized Medicare Supplement Benefit
							 Plan
Statutory Authority:
				  RCW
				  48.66.030(3)(a),
				  48.66.041, and
				  48.66.165. 09-24-052 (Matter No. R
				  2009-08), §
										284-66-232, filed 11/24/09,
				  effective 1/19/10. Statutory Authority:
				  RCW
				   48.02.060. 93-01-048 (Order 92-25), §
										284-66-232, filed 12/10/92,
				  effective 1/10/93. Statutory Authority:
				  RCW
				   48.02.060,
				  48.20.450,
				  48.20.460,
				  48.20.470,
				  48.30.010,
				  48.44.020,
				  48.44.050,
				  48.44.070,
				  48.46.030,
				  48.46.130 and
				  48.46.200. 92-06-021 (Order R
				  92-1), §
										284-66-232, filed 2/25/92,
				  effective 3/27/92.