Wash. Admin. Code § 284-66-232 - Form for medicare supplement refund calculation

Current through Register Vol. 22-07, April 1, 2022

MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR

TYPE

SMSBP(w)

For the State of

Washington Policy or Certificate Form No(s).

Company Name

NAIC Group Code

NAIC Company Code

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 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)

Total Earned Premium (line 3, col a) - Refunds Since Inception (line 6)

= Ratio 2

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)

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. Adjust Incurred Claims =

[Total Earned Premium (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 Year 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

SMSBP(w)

For the State of

Washington Policy or Certificate Form No(s).

Company Name

NAIC Group Code

NAIC Company Code

Person Completing This Exhibit

Title

Telephone Number

(w)

"SMSBP" = Standardized Medicare Supplement Benefit Plan

(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

Date

WORKSHEET #1 - INDIVIDUAL POLICIES

REPORTING FORM FOR TIME CALCULATION OF

BENCHMARK RATIO SINCE INCEPTION

FOR INDIVIDUAL POLICIES

FOR CALENDAR YEAR

TYPE

SMSBP (P)

FOR THE STATE OF WASHINGTON

Washington Policy or Certificate Form No.

Company Name

NAIC Group Code

NAIC Company Code

Address

Person Completing This Exhibit

Title

Telephone Number

(a)

Year

(b)

Earned

Premium

(c)

Factor

(d)

(b) x (c)

(e)

Cumulative

Loss Ratio

(f)

(d) x (e)

(g)

Factor

(h)

(b) x (g)

(i)

Cumulative

Loss Ratio

(j)

(h) x (i)

(o)

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+1

4.175

0.493

8.684

0.725

0.77

Total:

(k):

(1):

(m):

(n):

FN for 15+1: 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: (1 + n) / (k + m):

(a):

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.)

(b):

For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

k =

1 =

m =

n =

Total of Column "d"

Total of Column "f"

Total of Column "h"

Total of Column "j"

(o):

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 ratio displayed on this worksheet. They are shown here for informational purposes only.

(p)

"SMSBP" = Standardized Medicare Supplement Benefit Plan

WORKSHEET #1 - GROUP POLICIES

REPORTING FORM FOR TIME CALCULATION OF

BENCHMARK RATIO SINCE INCEPTION

FOR GROUP POLICIES

FOR CALENDAR YEAR

TYPE

SMSBP (P)

FOR THE STATE OF WASHINGTON

Washington Policy or Certificate Form No.

Company Name

NAIC Group Code

NAIC Company Code

Address

Person Completing This Exhibit

Title

Telephone Number

(a)

Year

(b)

Earned

Premium

(c)

Factor

(d)

(b) x (c)

(e)

Cumulative

Loss Ratio

(f)

(d) x (e)

(g)

Factor

(h)

(b) x (g)

(i)

Cumulative

Loss Ratio

(j)

(h) x (i)

(o)

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+

4.175

0.567

8.684

0.838

0.89

Total:

(k):

(1):

(m):

(n):

FN for 15+: 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: (1 + n) / (k + m):

(a):

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.)

(b):

For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

k =

1 =

m =

n =

Total of Column "d"

Total of Column "f"

Total of Column "h"

Total of Column "j"

(o):

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 ratio displayed on this worksheet. They are shown here for informational purposes only.

(p)

"SMSBP" = Standardized Medicare Supplement Benefit Plan

Notes

Wash. Admin. Code § 284-66-232

Statutory Authority: RCW 48.66.030(3)(a), 48.66.041, and 48.66.165. 09-24-052 (Matter No. R 2009-08), § 284-66-232, filed 11/24/09, effective 1/19/10. Statutory Authority: RCW 48.02.060. 93-01-048 (Order 92-25), § 284-66-232, filed 12/10/92, effective 1/10/93. Statutory Authority: RCW 48.02.060, 48.20.450, 48.20.460, 48.20.470, 48.30.010, 48.44.020, 48.44.050, 48.44.070, 48.46.030, 48.46.130 and 48.46.200. 92-06-021 (Order R 92-1), § 284-66-232, filed 2/25/92, effective 3/27/92.

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