N.H. Code Admin. R. Ins 1905.27
(a) The commissioner, upon the commissioner’s own initiative or upon request by an insurer, shall waive any requirement of this chapter if such waiver does not contradict the objective or intent of the rule and:
(d) A request for a waiver shall specify the basis for the waiver and proposed alternative, if any.
Source. #12370, eff 10-13-17
Appendix A.
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 Exhibit_________________
Title_______________________________________ Telephone Number________________________
Line
(b) Incurred Claims4
10. Tolerance Permitted (obtained from credibility table)
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"
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 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
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 Exhibit______________________________
Title________________________________________________
Telephone Number____________________________________
(a)3
(b)4
(j) (o)5
Earned
Cumulative
Cumulative
Policy Year
Year
Premium
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+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 Name____________________________________________________
NAIC Group Code__________________________________________________
NAIC Company Code_______________________________________________
Address__________________________________________________________
Person Completing Exhibit___________________________________________
Title_____________________________________________________________
Telephone Number_________________________________________________
(a)3
(b)4
(j) (o)5
9. Section 1882 of the federal Social Security Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in Appendix C remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers should use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously.
[Original disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for policies that provide benefits for specified limited services.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
any of the services covered by the policy are also covered by Medicare
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
hospital or medical expenses up to the maximum stated in the policy
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits because Medicare generally pays for most of the expenses for the diagnosis and treatment of the specific conditions or diagnoses named in the policy.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
any expenses or services covered by the policy are also covered by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in Medicare Part D]
hospice
other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when:
any expenses or services covered by the policy are also covered by Medicare; or
it pays the fixed dollar amount stated in the policy and Medicare covers the same event
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice care
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items & services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Original disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
Important Notice to Persons on Medicare
This Insurance Duplicates Some Medicare Benefits
This is not Medicare Supplement Insurance
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
This insurance duplicates Medicare benefits when it pays:
the benefits stated in the policy and coverage for the same event is provided by Medicare
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for policies that provide benefits for expenses incurred for an accidental injury only.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses that result from accidental injury. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for policies that provide benefits for specified limited services.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits under this policy.
This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for policies that reimburse expenses incurred for specified diseases or other specified impairments. This includes expense-incurred cancer, specified disease and other types of health insurance policies that limit reimbursement to named medical conditions.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy. Medicare generally pays for most or all of these expenses.
This insurance provides limited benefits, if you meet the policy conditions, for hospital or medical expenses only when you are treated for one of the specific diseases or health conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for policies that pay fixed dollar amounts for specified diseases or other specified impairments. This includes cancer, specified disease, and other health insurance policies that pay a scheduled benefit or specific payment based on diagnosis of the conditions named in the policy.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed amount, regardless of your expenses, if you meet the policy conditions, for one of the specific diseases or health conditions named in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for indemnity policies and other policies that pay a fixed dollar amount per day, excluding long-term care policies.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays a fixed dollar amount, regardless of your expenses, for each day you meet the policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for policies that provide benefits upon both an expense-incurred and fixed indemnity basis.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice care
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items & services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
[Alternative disclosure statement for other health insurance policies not specifically identified in the preceding statements.]
Important Notice to Persons on Medicare
This Is Not Medicare Supplement Insurance
Some health care services paid for by Medicare may also trigger the payment of benefits from this policy.
This insurance provides limited benefits if you meet the conditions listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement insurance.
Medicare generally pays for most or all of these expenses.
Medicare pays extensive benefits for medically necessary services regardless of the reason you need them. These include:
hospitalization
physician services
hospice
[outpatient prescription drugs if you are enrolled in Medicare Part D]
other approved items and services
This policy must pay benefits without regard to other health benefit coverage to which you may be entitled under Medicare or other insurance.
BEFORE YOU BUY THIS INSURANCE
Ö Check the coverage in all health insurance policies you already have.
Ö For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.
Ö For help in understanding your health insurance, contact your state insurance department or state [health] insurance [assistance] program [SHIP].
Earned
Cumulative
Cumulative
Policy Year
Year
Premium
Factor
(b)x(c)
Loss Ratio
(d)x(e)
Factor
(b)x(g)
Loss Ratio
(h)x(i)
Loss Ratio
1
2.770
0.442
0.000
0.000
0.40
2
4.175
0.493
0.000
0.000
0.55
3
4.175
0.493
1.194
0.659
0.65
4
4.175
0.493
2.245
0.669
0.67
5
4.175
0.493
3.170
0.678
0.69
6
4.175
0.493
3.998
0.686
0.71
7
4.175
0.493
4.754
0.695
0.73
8
4.175
0.493
5.445
0.702
0.75
9
4.175
0.493
6.075
0.708
0.76
10
4.175
0.493
6.650
0.713
0.76
11
4.175
0.493
7.176
0.717
0.76
12
4.175
0.493
7.655
0.720
0.77
13
4.175
0.493
8.093
0.723
0.77
14
4.175
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.
Appendix B.
FORM FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
Company Name: ________________________________________________
Address: ________________________________________________
________________________________________________
Phone Number: ________________________________________________
Due March 1, annually
The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
Policy and Date of
Certificate # Issuance
___________________________________
Signature
___________________________________
Name and Title (please type)
___________________________________
Date
Appendix C.
DISCLOSURE STATEMENTS
Instructions for Use of the Disclosure Statements for
Health Insurance Policies Sold to Medicare Beneficiaries
that Duplicate Medicare