PURPOSE: This regulation facilitates the collecting of relevant Medicare supplement premium loss data in order to ensure that mandated loss ratios are being met by insurers who sell Medicare supplement insurance. (1) Medicare supplement loss data must be reported annually on or before April 1 of each year for the twelve (12) months ending December 31 next preceding on the forms which follow as appendices. (A) Appendix A shall be used for reports due on or before April 1,199O. (B) Appendix B shall be used for reports due after April 1,199O. (2) Mass-marketed policies shall be considered to be individual policies. (3) Group insurance business is to be reported for all certificates issued pursuant to any group policy delivered or issued for delivery in this state. No group insurance business should be reported for group policies delivered or issued for delivery outside this state. Auth: sections 374.045, 374.190 and 376.870, RSMo (1986) and 376.874.2., RSMo (Cum. Supp. 1989). This rule was preuionsly filed as 4 CSR 190-14.117. Original rule filed Feb. 4,1987, effective July 1, 1987. Amended: Filed Sept. 14, 1989, effective Jan. 1,199O.

(8’20’g1)

20CSR600-l--INSURANCE

APPENDIX A

Reporting Instructions

Medicare Supplement Insurance Experience Report

1. 1. Policy Form Number: A report form should be filled out for each Medicare supplement policy. Asterisk any policy that is mass marketed.
2. 2. Year First Issued in Missouri: Self-explanatory.
3. 3. Grouu or Individual Policy: Use the Roman Numeral “I” if the policy is a group policy or “II” if an individual policy or a mass-marketed form.
4. 4. Renewability Type: Enter a two-digit alphabetic code from the following table: OR-Optionally Renewable CR-Conditionally Renewable or Quasi-Guaranteed GR-Guaranteed Renewable NC-Non-Cancellable
5. 5. Missouri Inforce Policy Counts: Average count for reporting year, calculated by summing monthly inforce count for year and dividing by 12 or using the inforce count of mid-reporting period. The count for group business is the number of certificate holders residing in this state; the count for individual business is the number of policyholders in the state. Number insured under this policy for: 1 year, etc. This number should be the number that have been insured for 1 (1 . 5 years+) or less, for example, if an individual has been insured for less than two years, report him/her as part of the count for “1 year.”
6. 6. Nationwide Inforce Policy Counts: Average nationwide count for reporting year, calculated the same for Missouri Inforce Policy counts. Number insured under this policy for: (Calculate same as Missouri Inforce Counts.)
7. 7. Premium Data: Net Premium Written: Premium written less any refund of premium. Net Premium Earned: Current year premium earned plus premium from prior year earned in current year.

8. 8. Losses Incurred Data: Note: Losses Paid and Losses Incurred exclude administrative expense and all loss adjustment expense.

   1. a. Losses Incurred and Paid Current Year: Calculate the losses incurred and paid during the current year being reported.
   2. b. E;gf Prior Year and Paid Current Year: Calculate losses which were incurred in the prior year and paid in the current year being
   3. c. Pajd Current Year: Self-explanatory.
   4. d. Due and &maid Current Year: Calculate losses due and outstanding at the end of the current reporting year, excluding those incurred but not reported.
   5. e. Due and Unpaid Prior Year: Calculate losses due and outstanding at the end of the prior reporting year, excluding incurred but not reported.
   6. f. Change in Reserve: Self-explanatory.
   7. g. IBNR Losses Due and Unpaid Current Year: Calculate losses due and incurred but not reported at end of current reporting year.
   8. h. IBNR Losses Due and Unpaid Prior Year: Calculate losses due and incurred but not reported at the end of the prior reporting year.
   9. i. Change in IBNR Reserve: Self-explanatory.

   10. j. Total Losses Incurred Current Year: Self-explanatory.

       CODEOFSTATEREGlJtATlONS (8/20/91) Ray D. Blunt Secretaly of state

Chapter l-Reports Other Than Annual Statement and Credit Insurance

State of Missouri

Medicare Supplement of Insurance Experience Report For Calendar Year

1. 2. Year First Issued in Missouri

1. 1. Policy Form No.
2. 3. This is a Group @)/Individual or Mass-Marketed (II) Policy
3. 4. Renewability Type (Use two-digit alphabetic code from instructions):
4. 5. Current Missouri Inforce Policy Counts Number insured under this policy for: ,’ 2 Years 3 Years 1 Year
5. 6. Current National Inforce Policy Counts Number insured under this policy for:
6. 7. Net Premium Written

7. 8. Losses Incurred:

   1. a. Losses incurred and paid current year
   2. b. Losses incurred prior year, paid current year
   3. c. Total losses paid current year
   4. d. Outstanding losses due and unpaid current year
   5. e. Outstanding losses due and unpaid prior year
   6. f. Change in reserve (d - e)
   7. g. IBNR losses due and unpaid current year
   8. h. IBNR losses due and unpaid prior year
   9. i. Change in IBNR reserve (g - h)
   10. j. TOTAL LOSSES INCURRED CURRENT YEAR (c t f t i)

NOTE: Missouri experience only except as indicated.

@I/20/91) 4 Years

Net Premium Earned

$ $

Signature of Person Preparing ReporVTitle

Print Name

Company Name

Address

Phone Number 20 CSR 600-1

5 Years+

$

$

$

NAIC Number 20 CSR 600-l-INSURANCE

Appendix B

Reporting Instructions

Medicare Supplement Insurance Experience Report

1. 1. Policy Form Number: A report form should be filled out for each Medicare Supplement policy form. Policy forms are not to be grouped unless they are nearly identical in Coverage 81. Premium. Do not include any experience for optional riders that may be attached to the policy form being reported.
2. 2. Year First Issued in Missouri: Self-explanatory.
3. 3. Is the same rate charged Countrywide for this policy form? Enter “Y” for Yes or “N” for No.
4. 4. Is this a Group Policy or an Individual Policy? Enter the appropriate code as follows: I=Group II=Individual Policy III=Mass Marketed or Direct Response
5. 5. Is the policy form Mass Marketed? Enter “Y” for Yes and “N” for No. Direct Response policies are to be considered Mass Marketed.

6. 6. Renewability Type: Enter a two-digit alphabetic code from the following table: OR=Optionally Renewable CR=Conditionally Renewable or Quasi-Guaranteed GR=Guaranteed Renewable NC=Non-Cancellable Missouri Experience: Enter experience in the following categories by policy duration as displayed in the report form for Missouri only: Duration-The number of years a policy has been in force. Round down to the nearest year when reporting experience. Number of Policies in Force Written Premium Earned Premium Paid Claim Count-Enter number of claims paid Paid Losses-Enter dollars paid for claims excluding loss adjustment expense Total Loss Reserves-Enter all reserves used to adjust paid losses to incurred losses Incurred Claim Counts-Enter the number of incurred claims Incurred Losses-Enter the dollars incurred Exclude all Administrative and Loss Adjustment Expenses. (Paid i Loss Reserve) Loss Ratio-Incurred Losses divided by Earned Premium Missouri Loss Reserves-Use Missouri data only.

   1. a. Unpaid Claim Reserves 1) Claim Reserves. current year: Enter the current year ending amount set aside to pay all claims outstanding no matter what year the loss was incurred. 2) Claim Reserves, prior year: Enter the prior year ending amount that was set aside to pay all claims outstanding no matter what year the loss was incurred. 3) Change in Unpaid Claim Reserves: Current Year Reserve-Prior Year Reserve

   2. b. Incurred but no Reported Reserves 1) IBNR Reserves. current vear: Enter the current vear endins amount set aside as IBNR reserve. 2) IBNR Reserves: prior year: Enter the prior yearending amount set aside as IBNR reserve. 3) Change in IBNR Reserves: Current Year Reserve-Prior Year Reserve

      1. c. Total Reserves added for Missouri this Calendar Year: Change in Unpaid Claim Reserves t Change in IBNR Reserves. This number must equal the total for all loss reserves by duration (line 6). List all Riders Attached to this Policy Form and Included in the-Experience Above-Provide.the rider number and a brief description of all riders included in the experience reported. Do not include optional riders in the experience reported.

         Roy 0. Blunt

6 CODEOFSTATE REGULATIONS (8/20/91) SeEretav of state 20 CSR 600-l Chapter l-Reports Other Than Annual Statement and Credit Insurance

1. (IO) Countrywide Experience: Please enter total countrywide experience for this policy form by duration for the following: Duration-The number of years a policy has been in force. Round down to the nearest year when reporting experience. Number of Policies in Force Written Premium Earned Premium Paid Claim Count-Enter number of claims paid Paid Losses-Enter dollars paid for claims excluding loss adjustment expense Total Loss Reserves-Enter all reserves used to adjust paid losses to incurred losses Incurred Claim Counts-Enter the number of incurred claims Incurred Losses-Enter the dollars incurred. Exclude all Administrative and Loss Adjustment Expenses. (Paid t Loss Reserve) Loss Ratio-Incurred Losses divided by Earned Premium

   Roy D. Blunt (8/20/91) CODEOFSTATEREGULATIONS 7

m 20CSR600-l--INSURANCE

State of Missouri

Medicare Supplement Insurance Experience Report For Calendar Year:-

1. 2. Year Fist Issued in Missouri

1. 1. Policy Form No.
2. 3. Is the same rats charged countrywide for this policy form?
3. 4. Group (I) or Individual (II) Policy?
4. 5. Is this policy Mass-Marketed? (“Y” or ‘IN”)?
5. 6. Renewability Type (Use two-digit alphabetic code from instructions):

6. 7. Missouri Experience:

   Number Paid Loss

   Duration of Policies Written Earned Paid T%t %Gd Ratio (Policy Year) in Force Premium Premium E% Losses Reserves Counts ‘EEd

7. 8. Missouri Loss Reserves:

8. A. Unpaid Claim Reserves 1) Claim Reserves, current year: 2) Claim Reserves, prior year

   3) Change in Unpaid Claim Reserves (1 - 2)

9. B. IBNR Reserves 1) IBNR Reserves, current year: 2) IBNR Reserves, prior year 3) Change in IBNR Reserves (1 - 2)

   1. C. Total Loss Reserves Added for Missouri This Calendar Year ((A.3) t B.3)

      (8/20/91) Roy 0. Blunt secretary 0‘ state

Chapter l-Reports Other Than Annual Statement and Credit Insurance

1. 9. List All Riders Attached to This Policy Form and Included in the Experience Above:

   Description

2. A. B.

Ei E: F. 10. Countrywide Experience:

Paid

Number Paid of Policies Written Earned

Duration Et% Losses Premium Premium (Policy Year) in Force

5*

;

i

\ Total 20 CSR 600-l

Iyyay;d Loss

22: ‘Ez?id Ratio Reserves Counts

Signature of an Officer of the Company/Title

Signature of Person Preparing Report/Title

Print Name of Person Preparing Report

Company Name

NAIC Group and Company Code

Address

Phone Number