Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 3 - Casualty Insurance › Appendix 8

Current through June 24, 2024
MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR
				YEAR_________________
TYPE 1
				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 (se worksheet for
							 Ratio 1)
8.
Experience 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 Experience
							 Ratio is less than the Benchmark Ration, 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 - 2,4999
10.0%
500 - 999
15.0%
If less than 500, no credibility.
11.
Adjusted 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) - Refund
							 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)]
______________
1 Individual, Group, Individual Medicare select, or Group
				Medicare select Only.
2. "SMSBP" = Standardized Medicare Supplement Benefit Plan -
				Use "P" for prestandardized 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."
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 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)
(d)
(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):
(u):
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 prestandardized plans. (For Wisconsin reports show the applicable policy
				form number or numbers for "pooled" business.)
3 Year I is the current calendar year-1. Year 2 is the current
				calendar year-2 (etc.). (Example: If the current year is 1990, 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 information 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 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)
(d)
(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):
(u):
Benchmark Ratio Since Inception: (l+n)/(k+m):
				___________________________
I Individual, Group, Individual Medicare Select, or Group
				Medicare Select Only.
2 "SMSBP"=Standardized Medicare Supplement Benefit Plan-Use "P"
				for prestandardized plans. (For Wisconsin reports show the applicable policy
				form number or numbers for "pooled" business.)
3 Year I 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 information purposes only.
6 To include the earned premium for all years prior to as well
				as the 15th year prior to the current year.