Connecticut Administrative Code
Title 38a - Insurance Department
495a - Medicare Supplement Insurance
Appendix A

Current through March 14, 2024

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1 Current Year's Experience

a. Total (all policy years)

b. Current year's issues5

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) = Ratio 2

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Tot. 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 Credibility Table

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"

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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 =

(Tot. 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)

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Benchmark Ratio (Ratio 1)

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.

_______________________________

Signature

_______________________________

Name - Please Type

_______________________________

Title - Please Type

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Date

REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES

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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.

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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.