The following format shall be used for reporting loss ratio experience:
MEDICARE SUPPLEMENT
HEALTH CARE SERVICE PLAN
CONTRACT EXPERIENCE EXHIBIT
For the year ended December 31, 20__.
For the State of California.
Of the ____ health care service plan.
Address (City, State, and Zip Code) ____
Person Completing this Exhibit ____
To be filed by June 30th following the filing under Section 1358.14 of the Health and Safety Code.
Costs for Health Care Services | |||
Prepaid or | Percentage | ||
Periodic | of Prepaid | ||
Charges | or Periodic | ||
Classification | Earned | Amount | Charges Earned |
Experience on Individual Plan Contracts 1. _____ Contracts issued _____ through 20__ _____ Reporting State_____ Nationwide 2. _____ Contracts issued _____ after 20__ _____ Reporting State_____ Nationwide Experience on Group Plan Contracts 1. _____ Contracts Issued _____ through 20__ _____ Reporting State_____ Nationwide 2. _____ Contracts Issued _____ after 20__ _____ Reporting State_____ Nationwide The undersigned officer hereby certifies that the company named above has complied with the requirements contained in the federal Omnibus Budget Reconciliation Act of 1987, Section 4081. Signature Title and name (please type) |
INSTRUCTIONS FOR COMPLETING MEDICARE SUPPLEMENT HEALTH CARE SERVICE PLAN CONTRACT EXPERIENCE EXHIBIT
DEFINITIONS
For purposes of this form:
Ca. Health and Saf. Code § 1358.146