Haw. Code R. § tit. 16, ch. 12, exh. D, app 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 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 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 1) | ||
| 8. | Experienced 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 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% |
| It less than 500, no credibility. | |
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".
Medicare Supplement Insurance Regulation
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 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 Patio, 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 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
Haw. Code R. tit. 16, ch. 12, exh. D, app A
The amended version of this section by Hawaii Administrative Rules Listing of Filings, 2019-01, July, eff. 8/1/2019 is not yet available.