Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 8

Current through August 26, 2024

Appendix 8

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.

Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 8