Appendix A- Reporting Form for Calculation of Loss Ratios

Appendix A- Reporting Form for Calculation of Loss Ratios APPENDIX A MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR. _ TYPEl SMSBP2 For the State of Company Name----------- NAIC Group Code NAIC Company Code ------------------ Address Person Completing Exhibit _ Title Telephone Number------ --- Line (a) Earned Premiums (b) Incurred Claims4 L Current Year's Experience a. Total (all policy years) b. Current year's issuess c. Net (for reporting purposes= 1a-1b 2. Past Years' Experience (allpolicv 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 I) 8. Experienced Ratio Since Inception (Ratio 2J Total Actual Incurred Qlaims line 3, CQl. b2 Total Earned Prem. (line 3, col. a)-Refunds Since Inception Qine 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) Med1. care supp1Jement Cred1" billty Table 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" · 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) <D (g) (h) (i) (j) (o)s Year Earned Premium Factor (b)x(c) Cumulative Loss Ratio (d)x(e) Factor (b)x(g) Cumulative Loss Ratio (h)x(i) Policy Yea1· Loss Ratio 2.770 0.507 0.000 0.000 0.46 · 4.175 0.567 0.000 0.000 0.63 ' 4.175 0.567 1.194 0.759 0.75 4.175 0.567 2.245 0.771 0.77 4.175 0.567 3.170 0.782 0.80 4.175 0.567 3.998 0.792 0.82 4.175 0.567 4.754 0.802 0.84 4.175 0.567 5.445 0.811 0.87 4:175 0.567 6.075 0.818 0.88 4.175 0.567 6.650 0.824 0.88 4.175 0.567 7.176 0.828 0.88 4.175 0.567 7.655 0.831 0.88 4.175 0.567 8.093 0.834 0.89 4.175 0.567 8.493 0.837 0.89 15+6 4.175 0.567 8.684 0.838 0.89 To.tal: (k): (1): (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 3 Year 1is the cunent calendar year·1. Year 2 is the current calendar year·2 (etc.) (Example: If the current year is 1991, then: Year 1is 1990; Yea1·2 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. 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.