S.D. Admin. R. 20:06:13 app A

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Current through Register Vol. 50, page 159, June 17, 2024

Appendix A - Medicare Supplement Refund Calculation Forms

APPENDIX A

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR_________________

TYPE (u) ___________________________ SMSBP (w) _________________________

For the State of ______________ Company Name ______________________________

NAIC Group Code ___________ NAIC Company Code _________________________

Address ________________________________________________________________

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 Year's 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 ---------------------------------------------------- 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 REFUND CALCULATION FORM

FOR CALENDAR YEAR_________________

TYPE (u) ___________________________ SMSBP (w) _________________________

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 =
[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 and/or credit against premiums to be used must be attached to this form.

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.

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR_________________

TYPE (u) ___________________________ SMSBP (w) _________________________

For the State of ______________ Company Name ______________________________

NAIC Group Code ___________ NAIC Company Code _________________________

Address ________________________________________________________________

Person Completing This Exhibit _____________________________________________

Title ____________________________________ Telephone Number_______________

(u) Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

(w) "SMSBP" = Standardized Medicare Supplement Benefit Plan - Use "P" for pre-standardized plans.

(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 - Please Type

____________________________________

Date

REPORTING FORM FOR THE CALCULATION OF BENCHMARK

RATIO SINCE INCEPTION FOR GROUP POLICIES

FOR CALENDAR YEAR____________________

TYPE (q) ____________________ SMSBP (p) _____________________

FOR THE STATE OF __________ Company Name _________________

NAIC Group Code ______________ NAIC Company Code ___________

Address ____________________________________________________

Person Completing This Exhibit _________________________________

Title ___________________________ Telephone Number ____________

(a)	(b)	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)
Earned	Cumulative	Cumulative	Policy Year
Year	Premium	Factor	(b) x (c)	Loss Ratio	(d) x (e)	Factor	(b) x (g)	Loss Ratio	(h) x (i)	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+	4.175	0.567	8.684	0.838	0.89
Total:	(k):	(l):	(m):	(n):

Benchmark Ratio Since Inception: (1 + n) / (k + m):

(a): Year 1 is the current calendar year - 1 (b): For the calendar year on the appropriate line in column (a),

Year 2 is the current calendar year - 2 (etc.) the premium earned during that year for policies issued in

(Example: If the current year is 1991, then: that year.

Year 1 is 1990; Year 2 is 1989, etc.).

Year 15+ is the earned premium for all years prior

to as well as the 15^th year prior to the current year.

(o): These loss ratios are not explicitly used in computing the (p): "SMSBP" = Standardized Medicare Supplement Benefit Plan.

benchmark loss ratios. They are the loss ratios, on

a policy year basis, which result in the cumulative (q): Individual Group, Individual Medicare Select, or Group Medicare

loss ratios displayed on this worksheet. They are shown Select Only.

here for informational purposes only.

REPORTING FORM FOR THE CALCULATION OF BENCHMARK

RATIO SINCE INCEPTION FOR INDIVIDUAL POLICIES

FOR CALENDAR YEAR____________________

TYPE (q) ____________________ SMSBP (p) _____________________

FOR THE STATE OF __________ Company Name _________________

NAIC Group Code ______________ NAIC Company Code ___________

Address ____________________________________________________

Person Completing This Exhibit _________________________________

Title ___________________________ Telephone Number ____________

(a)	(b)	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)
Earned	Cumulative	Cumulative	Policy Year
Year	Premium	Factor	(b) x (c)	Loss Ratio	(d) x (e)	Factor	(b) x (g)	Loss Ratio	(h) x (i)	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+	4.175	0.493	8.684	0.725	0.77
Total:	(k):	(l):	(m):	(n):

Benchmark Ratio Since Inception: (l + n) / (k + m):

(a): Year 1 is the current calendar year - 1

(b): For the calendar year on the appropriate line in column (a),

Year 2 is the current calendar year - 2 (etc.) the premium earned during that year for policies issued in that

(Example: If the current year is 1991, then: year.

Year 1 is 1990; Year 2 is 1989, etc.).

Year 15+ is the earned premium for all years prior

to as well as the 15^th year prior to the current year.

(o): These loss ratios are not explicitly used in computing the

( p): "SMSBP" = Standardized Medicare Supplement Benefit Plan.

benchmark loss ratios. They are the loss ratios, on

a policy year basis, which result in the cumulative

(q): Individual Group, Individual Medicare Select, or Group Medicare

loss ratios displayed on this worksheet. They are shown Select Only.

here for informational purposes only.

S.D. Admin. R. 20:06:13 app A

18 SDR 225, effective 7/17/1992; 31 SDR 214, effective 7/6/2005; 39 SDR 10, effective 8/1/2012.