The following format shall be used for reporting loss ratio experience:

MEDICARE SUPPLEMENT HEALTH CARE SERVICE PLAN CONTRACT EXPERIENCE EXHIBITFor 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

1.  Experience on plan contracts issued more than three years prior to the reporting year should 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 plan contracts issued in 1985 and prior should be shown separately from that of plan contracts issued in 1986 and later. For group coverage, the year of issue should be based on when the contract was issued if available; otherwise use the master plan contract year of issue.

2.  Allocation of reserves on a state-by-state basis should be on sound actuarial principles and be consistent from year to year.

3.  Membership or plan contract fees, if any, constitute, and should be included with, prepaid or periodic charges earned. Earned prepaid or periodic charges may be shown on an annual basis net of loadings for nonannual modes.

4.  Mass marketing group coverage subject to individual loss ratio standards should be included with individual plan contracts.

5.  Any dividends paid to subscribers should be included with costs for health care.

6.  Neither costs for health care services nor earned prepaid or periodic charges should be adjusted for changes in plan contract (additional) reserves.

DEFINITIONS

For purposes of this form:

1.  “Costs for health care services” means payment for health care services plus the increase in claim reserves. Claim reserves include only those unpaid liabilities for claims that have already been incurred. Costs for health care services in this exhibit do not include plan contract additional reserves.

(Added by Stats. 2000, Ch. 706, Sec. 2. Effective January 1, 2001.)