1. (a) A person who transacts the business of insurance and who provides medicare supplement policies shall comply with all provisions of 42 U.S.C. 1395ss, as amended by the Omnibus Budget Reconciliation Act of 1990.
2. (b) Certification of compliance with the requirements of (a) of this section must be in the form set out at the end of this subsection. The form must be completed in accordance with the following instructions: MEDICARE SUPPLEMENT INSURANCE EXPERIENCE EXHIBIT For the year ended December 31, 20 _________ ________________________ ________________________ ________________________ NAIC Group Code _________ NAIC Company Code _________ Person Completing This Exhibit _________ To be filed by June 30 following the Annual State- ment Filing _________ Incurred Claims _________ ClassificationPremiums EarnedAmount% of Premiums Earned _________ Experience on individual policies1. olicies issued through 20 _________ Reporting state . . . . . Nationwide . . . . . 2. olicies issued through 20 _________ Reporting state . . . . . Nationwide . . . . . Experience on group policies1. olicies issued through 20 _________ Reporting state . . . . . Nationwide . . . . . 2. olicies issued through 20 _________ Reporting state . . . . . Nationwide . . . . . _________ The undersigned officer hereby certifies that the company named above has complied with the requirements contained in 42 U.S.C. 1395ss as amended by Omnibus Budget Reconciliation Act of 1990. _________ Signature _________ Title and Name (Please Type)
3. (1) Experience on policies issued more than three years before the reporting year must be shown separately as indicated on the form. For example, for the reporting year ended 12/31/88 (filed on June 30, 1989), experience on policies issued in 1985 and earlier should be shown separately from that of policies issued in 1986 and later. For group insurance, the year of issue should be based on when the certificate was issued if available; otherwise use the master policy year of issue.
4. (2) Allocation of reserves on the state-by-state basis must be on sound actuarial principles and be consistent from year to year.
5. (3) Membership or policy fees, if any, must be included with premiums earned. Earned premiums may be shown on an annual basis net of loading for non-annual modes.
6. (4) Mass-marketed group insurance subject to individual loss ratio standards must be included with individual.
7. (5) Dividends must be included with incurred claims.
8. (6) Neither incurred claims nor earned premiums may be adjusted for changes in policy (additional) reserves.

(Eff. 8/8/90, Register 115; am 7/1/92, Register 122)