Appendix A

Regulations of Connecticut State Agencies

Sec. Appendix A.


Image of Appendix A Medicare Supplement Refund Calculation Form for Calendar Year ________

Image of Appendix A Reporting Form for The Calculation of Benchmark Ratio Since Inception For Group Policies For Calendar Year ________

Image of Appendix A Reporting Form for The Calculation of Benchmark Ratio Since Inception For Group Policies For Calendar Year ________

(a)3

(b)4

(c)

(d)

(e)

(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

(b)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

0.8

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

4.493

0.837

0.89

15+6

4.175

0.567

8.684

0.838

0.89

Total:

(k):

(l):

(m):

(n):

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

1Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

3Year 1 is the current calendar year 1

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

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.)

5These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, for pre-standardized plans which result in the cumulative loss ratios displayed on this worksheet.

2"SMSBP" = Standardized Medicare Supplement Benefit Plan. Use "P"

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.


Image of Appendix B Form for Reporting Medicare Supplement Policies

(a)3

(b)4

(c)

(d)

(e)

(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

(b)x(i)

Policy Year Loss Ratio

1

2.770

0.442

0.000

0.000

0.4

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

4.493

0.725

0.77

15+6

4.175

0.493

8.684

0.725

0.77

Total:

(k):

(l):

(m):

(n):

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

1Individual, Group, Individual Medicare Select, or Group Medicare Select Only.

3Year 1 is the current calendar year 1

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

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.)

5These loss ratios are not explicitly used in computing the benchmark loss ratios. They are the loss ratios, on a policy year basis, for pre-standardized plans which result in the cumulative loss ratios displayed on this worksheet.

2"SMSBP" = Standardized Medicare Supplement Benefit Plan. Use "P"

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.