R.C.S.A. § 38a-495a 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 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) = Ratio 2 --------------------------------------------- Tot. 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 3 Includes modal loadings and fees charges. 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 This 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 = (Tot. 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 the 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. 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 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): 1Individual, Group, Individual Medicare Select, or Group Medicare Select Only. 2"SMSBP" = Standardized Medicare Supplement Benefit Plan. Use "P" for pre-standardized plans 3Year 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.) 4For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year. 5These 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. 6To 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 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): 1Individual, Group, Individual Medicare Select, or Group Medicare Select Only. 2"SMSBP" = Standardized Medicare Supplement Benefit Plan. Use "P" for pre-standardized plans 3Year 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.) 4For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year. 5These 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. 6To include the earned premium for all years prior to as well as the 15th year prior to the current year. Notes: Section republished to update table formatting. (October 21, 2016) Notes: Typographical content and placement errors in and under the 'REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIOS SINCE INCEPTION FOR GROUP POLICIES' were corrected as follows: the typographical error '4.493' printed in column G, row 14 was corrected to '8.493;' the typographical error '(b)x(i)' printed in column J, row 1 was corrected to '(h)x(i);' the phrase 'for pre-standardized plans' printed by mistake in note five (5) was moved to note two (2); note two (2) was placed in correct numerical sequence; the block of text beginning with the words 'Year 2' and ending with the words 'Year 2 is 1989; etc.),' printed by mistake in note four (4) was moved to note three (3); and the sentence, 'They are shown here for informational purposes only.' printed by mistake immediately preceding note (6) was moved to note five (5). (August 17, 2018) Notes: Typographical content and placement errors in and under the 'REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIOS SINCE INCEPTION FOR INDIVIDUAL POLICIES' were corrected as follows: the typographical error '4.493' printed in column G, row 14 was corrected to '8.493;' the typographical error '(b)x(i)' printed in column J, row 1 was corrected to '(h)x(i);' the phrase 'for pre-standardized plans' printed by mistake in note five (5) was moved to note two (2); note two (2) was placed in correct numerical sequence; the block of text beginning with the words 'Year 2' and ending with the words 'Year 2 is 1989; etc.),' printed by mistake in note four (4) was moved to note three (3); and the sentence, 'They are shown here for informational purposes only.' printed by mistake immediately preceding note (6) was moved to note five (5). (August 17, 2018)