Form HL-MS-1 "Medicare Supplement Refund Calculation Form" - Kentucky

What Is Form HL-MS-1?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2009;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HL-MS-1 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form HL-MS-1 "Medicare Supplement Refund Calculation Form" - Kentucky

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MEDICARE SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR_________________
______________________________
TYPE
________________________________ SMSBP
1
2
For the State of
Kentucky __________ Company Name _______________________
NAIC Group Code ______________________ NAIC Company Code __________________
Address _______________________________ Person Completing Exhibit _____________
Title __________________________________ Telephone Number ____________________
(a)
(b)
Line
Earned
Incurred
Premium
Claims
3
4
1. Current Year’s 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
HL-MS-1 (July 2009)
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR_________________
______________________________
TYPE
________________________________ SMSBP
1
2
For the State of
Kentucky __________ Company Name _______________________
NAIC Group Code ______________________ NAIC Company Code __________________
Address _______________________________ Person Completing Exhibit _____________
Title __________________________________ Telephone Number ____________________
(a)
(b)
Line
Earned
Incurred
Premium
Claims
3
4
1. Current Year’s 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
HL-MS-1 (July 2009)
Medicare Supplement Credibility Table
Life Years 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.
_______________________________________________________
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”
2
HL-MS-1 (July 2009)
MEDICARE SUPPLEMENT REFUND CALCULATION FORM
FOR CALENDAR YEAR_________________
______________________________
TYPE
________________________________ SMSBP
1
2
For the State of
Kentucky ___________ Company Name _______________________
NAIC Group Code ______________________ NAIC Company Code __________________
Address _______________________________ Person Completing Exhibit _____________
Title __________________________________ Telephone Number ____________________
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
3
HL-MS-1 (July 2009)
REPORTING FORM FOR THE CALCULATION OF BENCHMARK
RATIO SINCE INCEPTION FOR GROUP POLICIES
FOR CALENDAR YEAR____________________
TYPE¹ ________________________________ SMSBP² ______________________________
For the State of
Kentucky ___________ Company Name _______________________
NAIC Group Code ______________________ NAIC Company Code __________________
Address _______________________________ Person Completing Exhibit _____________
Title __________________________________ Telephone Number ____________________
(a)³
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(o)
4
5
Year
Earned
Cumulative
Cumulative
Policy
Premium
Year
Factor
(b)x(c)
Loss Ratio
(d)x(e)
Factor
(b)x(g)
Loss Ratio
(h)x(i)
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+
4.175
0.567
8.684
0.838
0.89
6
Total:
(k):
(l):
(m):
(n):
4
HL-MS-1(July 2009)
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 15
year prior to the current year.
th
5
HL-MS-1(July 2009)
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