The following forms are to be used for reporting loss ratios and calculating refunds for credits required under Regulation .11B of this chapter:

1. A. Medicare Supplement Refund Calculation Form. ¹ Individual, Group, Individual Medicare Select, or Group Medicare Select Only ² “SMSBP” = Standardized Medicare Supplement Benefit Plan—Use “P” for prestandarized 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” I certify that the above information and calculations are true and accurate to the best of my knowledge and belief. ________________________________

   MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR _____
   TYPE1___________________________________	SMSBP2_______________________________________
   For the State of____________________________	Company Name ________________________________
   NAIC Group Code _________________________	NAIC Company Code ___________________________
   Address ________________________________	Person Completing This Exhibit ____________________
   Title ___________________________________	Telephone Number _____________________________

   line		(a) Earned Premium3	(b) Incurred Claims4
   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 (Ratio 2)
   	Total Actual Incurred Claims (line 3, col b) 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 REFUND CALCULATION FORM FOR CALENDAR YEAR _____
   TYPE1___________________________________	SMSBP2_______________________________________
   For the State of____________________________	Company Name ________________________________
   NAIC Group Code _________________________	NAIC Company Code ___________________________
   Address ________________________________	Person Completing This Exhibit ____________________
   Title ___________________________________	Telephone Number _____________________________

   line
   11	Adjustments 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)/ 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.
   	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.

   MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR _____
   TYPE1___________________________________	SMSBP2_______________________________________
   For the State of____________________________	Company Name ________________________________
   NAIC Group Code _________________________	NAIC Company Code ___________________________
   Address ________________________________	Person Completing This Exhibit ____________________
   Title ___________________________________	Telephone Number _____________________________

2. B. Reporting Form for Benchmark Ratio for Group Policies. 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 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.

   REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES FOR CALENDAR YEAR ________
   TYPE1___________________________________	SMSBP2_______________________________________
   For the State of____________________________	Company Name ________________________________
   NAIC Group Code _________________________	NAIC Company Code ___________________________
   Address ________________________________	Person Completing This Exhibit ____________________
   Title ___________________________________	Telephone Number _____________________________

   (a)3	(b)4	(c)	(d)	(e)	(f)	(g)	(h)	(i)	(j)	(o)5
   Year	Earned Premium	Factor	(b) × (c)	Cumulative Loss Ratio	(d) × (e)	Factor	(b) × (g)	Cumulative Loss Ratio	(h) × (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		8.493		0.837		0.89
   15+6		4.175		0.567		8.684		0.838		0.89
   			________		________		________		________
   Total:		(k):		(l):		(m):		(n):

3. C. Reporting Form for Benchmark Ratio for Individual Policies. 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 prestandardized plans ³Year 1 is the current 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.

   REPORTING FORM FOR THE CALCULATION OF BENCHMARK RATIO SINCE INCEPTION FOR GROUP POLICIES FOR CALENDAR YEAR ________
   TYPE1___________________________________	SMSBP2_______________________________________
   For the State of____________________________	Company Name ________________________________
   NAIC Group Code _________________________	NAIC Company Code ___________________________
   Address ________________________________	Person Completing This Exhibit ______________________________________________
   Title ___________________________________	Telephone Number _____________________________

Signature

________________________________

Name-Please Type

________________________________

Title-Please Type

________________________________

Date

Authority: Health-General Article, §§19-705 and 19-706; Insurance Article, §§2-109 and 8-403(b), Title 15, Subtitle 9, and Title 27; Annotated Code of Maryland

Effective date:

Regulations .01—.21 adopted as an emergency provision effective July 14, 1992 (19:16 Md. R. 1466); adopted permanently effective August 3, 1992 (19:15 Md. R. 1389)

Chapter revised effective April 1, 1996 (23:6 Md. R. 475)

Regulation .14A amended, and Regulation .21 repealed, and Regulations .22 and .23 recodified to Regulations .21 and .22, respectively, as an emergency provision effective April 25, 1996 (23:10 Md. R. 728); amended permanently effective September 10, 1996 (23:18 Md. R. 1317)

Chapter recodified from COMAR 09.30.90 to COMAR 31.10.06 effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .02 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .02 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061)

Regulation .02 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570)

Regulation .03 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .04B amended as an emergency provision effective January 1, 2000 (27:4 Md. R. 452); emergency status expired June 28, 2000

Regulation .04B amended effective August 21, 2000 (27:16 Md. R. 1526)

Regulation .06 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .08 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061)

Regulation .08 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570)

Regulation .09 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .09-1 adopted as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); adopted permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .09-1 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061)

Regulation .09-1 amended as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; amended permanently effective April 1, 2002 (29:6 Md. R. 570)

Regulation .13 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .13 amended as an emergency provision effective July 25, 2000 (27:16 Md. R. 1520); amended permanently effective November 13, 2000 (27:22 Md. R. 2061)

Regulation .22 amended as an emergency provision effective January 1, 1999 (26:1 Md. R. 18); amended permanently effective March 22, 1999 (26:6 Md. R. 489)

Regulation .23 adopted as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; adopted permanently effective April 1, 2002 (29:6 Md. R. 570)

Regulation .24 adopted as an emergency provision effective October 1, 2001 (28:23 Md. R. 2053); emergency status expired March 29, 2002; adopted permanently effective April 1, 2002 (29:6 Md. R. 570)

Chapter revised effective January 1, 2006 (32:18 Md. R. 1522)

Regulation .02B amended effective September 21, 2009 (36:19 Md. R. 1439); January 14, 2019 (46:1 Md. R. 13)

Regulation .06A amended effective August 21, 2023 (50:16 Md. R. 729)

Regulation .07A amended effective September 21, 2009 (36:19 Md. R. 1439)

Regulation .08 amended effective September 21, 2009 (36:19 Md. R. 1439)

Regulation .09 amended effective September 21, 2009 (36:19 Md. R. 1439)

Regulation .13 amended effective September 21, 2009 (36:19 Md. R. 1439)

Regulation .13E amended effective November 29, 2010 (37:24 Md. R. 1660)

Regulation .26 adopted effective June 29, 2009 (36:13 Md. R. 901)

Regulations .27—.30 adopted effective September 21, 2009 (36:19 Md. R. 1439)

Regulation .28H amended effective November 29, 2010 (37:24 Md. R. 1660); January 14, 2019 (46:1 Md. R. 13)

Regulation .29 repealed effective November 29, 2010 (37:24 Md. R. 1660)

Regulation .30 amended effective January 14, 2019 (46:1 Md. R. 13)

Regulation .30I, J amended effective November 29, 2010 (37:24 Md. R. 1660)

Regulation .31 adopted effective January 14, 2019 (46:1 Md. R. 13)