South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
69-46 APPENDIX A - MEDICARE SUPPLEMENT REFUND CALCULATION FORM

Universal Citation: SC Code Regs 69-46 APPENDIX A

APPENDIX A. MEDICARE SUPPLEMENT REFUND CALCULATION FORM

FOR CALENDAR YEAR

TYPE 1

SMSBP 2

For the State ofCompany Name
NAIC Group CodeNAIC Company Code
AddressPerson Conducting Exhibit
TitleTelephone Number

Line (a) Earned (b) Incurred

Premium 3 Claims 4

1. Current Years' Experience
a. Total (all policy years)

b. Current year's issues 5

c. Net (for reporting purposes= 1a-1b
2. Past Years' 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 (see worksheet for Ratio 1)

8. Experienced 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 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)

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 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''.

Medicare Supplement Credibility Table

Life Years Exposed
Since InceptionTolerance
10,000 +0.0%
5,000 — 9,9995.0%
2,500 — 4,9997.5%
1,000 — 2,49910.0%
500 — 99915.0%
If less than 500, no credibility
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
[Total 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)/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 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 GROUP POLICIES

FOR CALENDAR YEAR

TYPE 1

SMSBP 2

For the State ofCompany Name
NAIC Group Code NAICCompany Code
AddressPerson Conducting Exhibit
TitleTelephone Number

(a)3(b)4(c)(d)(e)(f)(g)(h)(i)(1)

(o)5

YearEarned PremiumFactor(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): (n):
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 pre-standardized plans.

3 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.).

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 informational 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 INDIVIDUAL POLICIES
FOR CALENDAR YEAR_______________

TYPE1

SMSBP2

For the State of
Company NameCompany Name
NAIC Group CodeNAIC Company Code
AddressPerson Conducting Exhibit
TitleTelephone Number

(a)3(b)4(c)(d)(e)(f)(g)(h)(i)

(o)5

Year Earned PremiumFactor(b)x(c)Cumulative Loss Ratio(d)x(e)Factor(b)x(g)Cumulative Loss Ratio(h)x(i)Policy Year Loss Ratio
12.770 0.442 0.000 0.000 0.40
24.175 0.493 0.000 0.000 0.55
34.175 0.493 1.194 0.659 0.65
44.175 0.493 2.245 0.669 0.67
54.175 0.493 3.170 0.678 0.69
64.175 0.493 3.998 0.686 0.71
74.175 0.493 4.754 0.695 0.73
84.175 0.493 5.445 0.702 0.75
94.175 0.493 6.075 0.708 0.76
104.175 0.493 6.650 0.713 0.76
114.175 0.493 7.176 0.717 0.76
124.175 0.493 7.655 0.720 0.77
134.175 0.493 8.093 0.723 0.77
144.175 0.493 8.493 0.725 0.77

15+6

4.175 0.493 8.684 0.725 0.77
Total: (k): (l) (m): (n):
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 pre-standardized plans.

3 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.).

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 informational purposes only.

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

HISTORY: Added by State Register Volume 13, Issue 1, adopted Jan. 27, 1989, eff July 1, 1989. Amended by State Register Volume 14, Issue 6, eff June 22, 1992; State Register Volume 14, Issue 6, eff June 22, 1990; State Register Volume 15, Issue 12, adopted Dec. 27, 1991, eff May 1, 1992; State Register Volume 20, Issue No. 4, eff April 28, 1; State Register Volume 23, Issue No. 3, eff March 26, 1999; State Register Volume 27, Issue No. 10, eff October 24, 2003; State Register Volume 29, Issue No. 7, eff July 22, 2005; State Register Volume 33, Issue No. 5, eff May 22, 2009; SCSR 42-1 Doc. No. 4804, eff January 26, 2018.

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