Regulations of Connecticut State Agencies

Sec. Appendix 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 This Exhibit __________________________________________ 

Title _____________________________ Telephone Number ___________________

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 charges. 

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 REFUND CALCULATION FORM

FOR CALENDAR YEAR ____________

TYPE¹ ___________________________ SMSBP² _________________________ 

For the State of _____________________________________________________ 

Company Name _____________________________________________________ 

NAIC Group Code _________________ NAIC Company Code _______________ 

Address ___________________________________________________________ 

Person Completing This Exhibit ________________________________________ 

Title _____________________________ Telephone Number _________________

If the amount on line 13 is less than .005 times the annualized premium in force as of the 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.

I certify that the above information and calculations are true and accurate to the best of my knowledge and belief.

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 This Exhibit __________ 

Title ______________________________ Telephone Number _____________________

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.

³Year 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.)

⁴For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

⁵These 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.

⁶To 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 INDIVIDUAL POLICIES

FOR CALENDAR YEAR __________

TYPE¹ ____________________________ SMSBP² _____________________________ 

FOR THE STATE OF_________________ Company Name_______________________

NAIC Group Code ___________________ NAIC Company Code __________________ 

Address____________________________ Person Completing This Exhibit __________ 

Title ______________________________ Telephone Number _____________________

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.

³Year 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.)

⁴For the calendar year on the appropriate line in column (a), the premium earned during that year for policies issued in that year.

⁵These 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.

⁶To include the earned premium for all years prior to as well as the 15th year prior to the current year.

(Effective July 30, 1992; Amended December 1, 2005; Amended November 30, 2009; Amended April 4, 2019)

Notes: Section republished to update table formatting. (October 21, 2016)

Notes: Typographical content and placement errors in and under the 'REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIOS SINCE INCEPTION FOR GROUP POLICIES' were corrected as follows: the typographical error '4.493' printed in column G, row 14 was corrected to '8.493;' the typographical error '(b)x(i)' printed in column J, row 1 was corrected to '(h)x(i);' the phrase 'for pre-standardized plans' printed by mistake in note five (5) was moved to note two (2); note two (2) was placed in correct numerical sequence; the block of text beginning with the words 'Year 2' and ending with the words 'Year 2 is 1989; etc.),' printed by mistake in note four (4) was moved to note three (3); and the sentence, 'They are shown here for informational purposes only.' printed by mistake immediately preceding note (6) was moved to note five (5). (August 17, 2018)

Notes: Typographical content and placement errors in and under the 'REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIOS SINCE INCEPTION FOR INDIVIDUAL POLICIES' were corrected as follows: the typographical error '4.493' printed in column G, row 14 was corrected to '8.493;' the typographical error '(b)x(i)' printed in column J, row 1 was corrected to '(h)x(i);' the phrase 'for pre-standardized plans' printed by mistake in note five (5) was moved to note two (2); note two (2) was placed in correct numerical sequence; the block of text beginning with the words 'Year 2' and ending with the words 'Year 2 is 1989; etc.),' printed by mistake in note four (4) was moved to note three (3); and the sentence, 'They are shown here for informational purposes only.' printed by mistake immediately preceding note (6) was moved to note five (5). (August 17, 2018)