{"text_format":"1","workbook":"xlsx","n_sheets":9,"sheets":["Cover Page","Pt 1 Summary of Data","Pt 2 Premium and Claims","Pt 3 Expense Allocation","Pt 4 MLR Calculation","Pt 5 Additional Responses","Attestation","Support","Instructions"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":15,"comments":1,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Cover Page","index":0,"n_rows":22,"n_cols":3,"rows_kept":22,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care/Department of Insurance"]
[null,"Medical Loss Ratio Reporting Form "]
[null,"Dental Coverage"]
[]
[]
["1.","MLR Reporting Year","2019"]
["2.","Enter DMHC Health Plan ID. Insurers may leave this field blank"]
["3.","Legal Name","Madison National Life Insurance Company, Inc."]
["4.","DBA"]
["5.","Federal Tax Exempt Status? Please enter Yes or No","No"]
[]
[]
[]
[null,"Cell Key:"]
[null,"Blank cells require input from Health plan or Health insurer"]
[]
[]
[null,"Version 4.22.15"]
[null,"Revised Version 5.26.15"]
[null,"Revised Version 4.15.16 corrected dates for Cycle Year (CY)2015-2016 on TABs Parts 1, 2 and 4."]
[null,"Revised Version 5.10.17 12/31 and 3/31 Columns years to be auto populated on TABs Parts 1 and 2."]
[null,"Revised Version 5.20.19 Document Accessible"]

{"sheet":"Pt 1 Summary of Data","index":1,"n_rows":58,"n_cols":17,"rows_kept":58,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care/Department of Insurance"]
[null,"Medical Loss Ratio Reporting Form: Dental Coverage"]
[null,"Part 1 - Summary of Data"]
[null,null,null,null,null,null,null,null,null,{"$f":"CELL(\"filename\",A1)","v":"T:\\Accounting\\Banking & Payables\\State Assessments\\CA Filing\\2019\\[MNL Dental-MLR-Reporting-Form-2020 Final with Support.xlsm]Pt 1 Summary of Data"}]
[null,"Health Plan ID",null,null,null,null,null,"Federal Tax Exempt "]
[null,null,null,{"$f":"'Cover Page'!C7","v":0},null,null,null,{"$f":"'Cover Page'!C10","v":"No"}]
[null,"Legal Name"]
[null,null,null,{"$f":"'Cover Page'!C8","v":"Madison National Life Insurance Company, Inc."}]
[null,"dBA",null,null,"Part 1"]
[null,null,null,{"$f":"'Cover Page'!C9","v":0}]
[null,"MLR Reporting Year"]
[null,null,null,{"$f":"'Cover Page'!C6","v":"2019"}]
[]
[null,null,null,null,null,null,"Health Insurance Coverage",null,null,null,null,null,"Health Insurance Coverage"]
[null,null,null,null,null,null,"DHMO Products",null,null,null,null,null,"DPPO & Indemnity Products"]
[null,null,null,null,"Individual",null,"Small Group",null,"Large Group",null,"Individual",null,"Small Group",null,"Large Group"]
[null,null,null,null,"Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of "]
[null,null,null,"Part 1\nNOTE: REFER TO MLR INSTRUCTIONS FOR IMPORTANT ",{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(E18)+0,MONTH(E18)+3,DAY(E18)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(G18)+0,MONTH(G18)+3,DAY(G18)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(I18)+0,MONTH(I18)+3,DAY(I18)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(K18)+0,MONTH(K18)+3,DAY(K18)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(M18)+0,MONTH(M18)+3,DAY(M18)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(O18)+0,MONTH(O18)+3,DAY(O18)+0)","v":"2020-03-31"}]
[null,null,null,"INFORMATION ABOUT COMPLETING EACH COLUMN AND ROW.",1,2,3,4,5,6,7,8,9,10,11,12]
[null,"1.","Premium"]
[null,null,1.1000000000000001,"Total direct premium earned",{"$f":"'Pt 2 Premium and Claims'!E22+'Pt 2 Premium and Claims'!E23-'Pt 2 Premium and Claims'!E24-'Pt 2 Premium and Claims'!E25","v":0},{"$f":"'Pt 2 Premium and Claims'!F22+'Pt 2 Premium and Claims'!F23-'Pt 2 Premium and Claims'!F24-'Pt 2 Premium and Claims'!F25","v":0},{"$f":"'Pt 2 Premium and Claims'!G22+'Pt 2 Premium and Claims'!G23-'Pt 2 Premium and Claims'!G24-'Pt 2 Premium and Claims'!G25","v":0},{"$f":"'Pt 2 Premium and Claims'!H22+'Pt 2 Premium and Claims'!H23-'Pt 2 Premium and Claims'!H24-'Pt 2 Premium and Claims'!H25","v":0},{"$f":"'Pt 2 Premium and Claims'!I22+'Pt 2 Premium and Claims'!I23-'Pt 2 Premium and Claims'!I24-'Pt 2 Premium and Claims'!I25","v":0},{"$f":"'Pt 2 Premium and Claims'!J22+'Pt 2 Premium and Claims'!J23-'Pt 2 Premium and Claims'!J24-'Pt 2 Premium and Claims'!J25","v":0},{"$f":"'Pt 2 Premium and Claims'!K22+'Pt 2 Premium and Claims'!K23-'Pt 2 Premium and Claims'!K24-'Pt 2 Premium and Claims'!K25","v":328506.20383044193},{"$f":"'Pt 2 Premium and Claims'!L22+'Pt 2 Premium and Claims'!L23-'Pt 2 Premium and Claims'!L24-'Pt 2 Premium and Claims'!L25","v":318028.75},{"$f":"'Pt 2 Premium and Claims'!M22+'Pt 2 Premium and Claims'!M23-'Pt 2 Premium and Claims'!M24-'Pt 2 Premium and Claims'!M25","v":259822.79616955813},{"$f":"'Pt 2 Premium and Claims'!N22+'Pt 2 Premium and Claims'!N23-'Pt 2 Premium and Claims'!N24-'Pt 2 Premium and Claims'!N25","v":251613.1},{"$f":"'Pt 2 Premium and Claims'!O22+'Pt 2 Premium and Claims'!O23-'Pt 2 Premium and Claims'!O24-'Pt 2 Premium and Claims'!O25","v":0},{"$f":"'Pt 2 Premium and Claims'!P22+'Pt 2 Premium and Claims'!P23-'Pt 2 Premium and Claims'!P24-'Pt 2 Premium and Claims'!P25","v":0}]
[]
[null,"2.","Claims"]
[null,null,2.1,"Total incurred claims (MLR Form Part 2, Line 2.11)",{"$f":"'Pt 2 Premium and Claims'!E51","v":0},{"$f":"'Pt 2 Premium and Claims'!F51","v":0},{"$f":"'Pt 2 Premium and Claims'!G51","v":0},{"$f":"'Pt 2 Premium and Claims'!H51","v":0},{"$f":"'Pt 2 Premium and Claims'!I51","v":0},{"$f":"'Pt 2 Premium and Claims'!J51","v":0},{"$f":"'Pt 2 Premium and Claims'!K51","v":90645.489335953898},{"$f":"'Pt 2 Premium and Claims'!L51","v":98131.458114182198},{"$f":"'Pt 2 Premium and Claims'!M51","v":87993.510664046102},{"$f":"'Pt 2 Premium and Claims'!N51","v":91756.257730750789},{"$f":"'Pt 2 Premium and Claims'!O51","v":0},{"$f":"'Pt 2 Premium and Claims'!P51","v":0}]
[]
[null,"3.","Federal and State Taxes and Licensing or Regulatory Fees"]
[null,null,3.1,"Federal taxes and assessments incurred by the reporting health plan or health insurer during the MLR reporting year "]
[null,null,null,"  3.1 a  Federal income taxes deductible from premium in MLR calculations ",null,null,null,null,null,null,{"$f":"Support!E11*L28/(L28+N28)","v":19986.40326654461},{"$f":"Support!G11","v":24534.681258580917},{"$f":"Support!E11*N28/(L28+N28)","v":8553.5967334553916},{"$f":"Support!H11","v":10500.126844786166}]
[null,null,null,"  3.1 b  Other Federal Taxes (other than income tax) and assessments deductible from premium"]
[null,null,3.2,"State insurance, premium and other taxes incurred by the reporting health plan or heath insurer during the MLR reporting year (deductible from premium in MLR calculation)"]
[null,null,null,"  3.2 a   State income, excise, business, and other taxes"]
[null,null,null,"  3.2 b   State premium taxes ",null,null,null,null,null,null,{"$f":"Support!E9*L32/(L32+N32)","v":11380.908876181667},{"$f":"Support!G9","v":9359.9159112742509},{"$f":"Support!E9*N32/(L32+N32)","v":12174.091123818333},{"$f":"Support!H9","v":10012.246864888346}]
[null,null,null,"  3.2 c   Community benefit expenditures "]
[null,null,3.3,"Regulatory authority licenses and fees"]
[null,null,3.4,"Total Federal and State Taxes and fees to be excluded from premium",{"$f":"SUM(E$28:E$29,E$31,E$34+IF($H$6=\"No\",IF(MAX(E$32:E$33)=0,MIN(E$32:E$33),MAX(E$32:E$33)),SUM(E$32:E$33)))","v":0},0,0,0,0,0,31367.312142726278,33894.597169855166,20727.687857273726,20512.37370967451,0,0]
[]
[null,"4.","Non-Claims Costs "]
[null,null,4.0999999999999996,"Direct sales salaries and benefits"]
[null,null,4.2,"Agents and brokers fees and commissions",null,null,null,null,null,null,{"$f":"Support!E7*L39/(L39+N39)","v":44455.844860856509},{"$f":"Support!G7","v":36561.687573088595},{"$f":"Support!E7*N39/(L39+N39)","v":47554.155139143477},{"$f":"Support!H7","v":39109.821631810766}]
[null,null,4.3,"Other taxes"]
[null,null,null,"4.3a   Taxes and assessments (exclude amounts reported in Section 3 or Line 10) \n"]
[null,null,null,"4.3b   Fines and penalties of regulatory authorities (exclude amounts reported in Line 3.3)"]
[null,null,4.4000000000000004,"Other general and administrative expenses",null,null,null,null,null,null,{"$f":"Support!E8*L43/(L43+N43)","v":69406.391851560023},{"$f":"Support!G8","v":57081.595287853001},{"$f":"Support!E8*N43/(L43+N43)","v":74243.608148439962},{"$f":"Support!H8","v":61059.845930370757}]
[null,null,4.5,"Total non-claims costs",{"$f":"SUM(SUM(E38:E39)+SUM(E41:E43))","v":0},{"$f":"SUM(SUM(F38:F39)+SUM(F41:F43))","v":0},0,0,0,0,113862.23671241653,93643.282860941603,121797.76328758344,100169.66756218152,0,0]
[]
[null,"5.","Other Indicators or information "]
[null,null,5.0999999999999996,"Number of covered lives",null,null,null,null,null,null,224,224,96,96,null,null,{"$f":"+N47+L47","v":320}]
[null,null,5.2,"Member months",null,null,null,null,null,null,6321,6321,2755,2755]
[null,null,5.3,"Number of life-years",{"$f":"E48/12","v":0},{"$f":"F48/12","v":0},0,{"$f":"H48/12","v":0},0,0,526.75,526.75,{"$f":"M48/12","v":229.58333333333334},{"$f":"N48/12","v":229.58333333333334},0,0]
[null,null,null,null,{"$f":"\"Grand Total as of \"&\"\"&TEXT(E$18,\"MM/DD/YYYY\")&\" for ALL markets in col. 1-12.\"","v":"Grand Total as of 12/31/2019 for ALL markets in col. 1-12."}]
[null,"6.","Net investment income and other gain / (loss) ",null,{"$f":"1675+83+226","v":1984}]
[null,"7.","Other Federal income taxes (exclude taxes on Line 3.1a and 3.1b) "]
[]
[null,"Cell Keys:"]
[null,null,"Blank cells require input from Health plan or Health insurer"]
[null,null,"Grey cells require no data input "]
[null,null,"Pink cells require no data input - locked down"]
[null,null,"Blue cells: computed cell (formula cell)"]

{"sheet":"Pt 2 Premium and Claims","index":2,"n_rows":58,"n_cols":16,"rows_kept":58,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care/Department of Insurance"]
[null,"Medical Loss Ratio Reporting Form: Dental Coverage"]
[null,"Part 2 - Premium and Claims"]
[]
[null,"Health Plan ID"]
[null,null,null,{"$f":"'Cover Page'!C7","v":0}]
[null,"Legal Name"]
[null,null,null,{"$f":"'Cover Page'!C8","v":"Madison National Life Insurance Company, Inc."}]
[null,"dBA",null,null,"Part 2"]
[null,null,null,{"$f":"'Cover Page'!C9","v":0}]
[null,"MLR Reporting Year"]
[null,null,null,{"$f":"'Cover Page'!C6","v":"2019"}]
[]
[]
[null,null,null,null,null,null,"Health Insurance Coverage",null,null,null,null,null,"Health Insurance Coverage"]
[null,null,null,null,null,null,"DHMO Products",null,null,null,null,null,"DPPO & Indemnity Products"]
[null,null,null,null,"Individual",null,null,"Small Group","Large Group",null,"Individual",null,"Small Group",null,"Large Group"]
[null,null,null,null,"Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of ","Total as of "]
[null,null,null,"Part 2\nNOTE: REFER TO MLR INSTRUCTIONS FOR IMPORTANT ",{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(E19)+0,MONTH(E19)+3,DAY(E19)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(G19)+0,MONTH(G19)+3,DAY(G19)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(I19)+0,MONTH(I19)+3,DAY(I19)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(K19)+0,MONTH(K19)+3,DAY(K19)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(M19)+0,MONTH(M19)+3,DAY(M19)+0)","v":"2020-03-31"},{"$f":"\"12/31/\"&\"\"&'Cover Page'!C$6","v":"12/31/2019"},{"$f":"DATE(YEAR(O19)+0,MONTH(O19)+3,DAY(O19)+0)","v":"2020-03-31"}]
[null,null,null,"INFORMATION ABOUT COMPLETING EACH COLUMN AND ROW.",1,2,3,4,5,6,7,8,9,10,11,12]
[null,"1.","Premium:"]
[null,null,1.1000000000000001,"Direct premium written",null,null,null,null,null,null,{"$f":"587702*L22/(L22+N22)","v":328111.65898801154},318028.75,{"$f":"587702*N22/(L22+N22)","v":259590.34101198852},251613.1]
[null,null,1.2,"Unearned premium prior year",null,null,null,null,null,null,442,null,270]
[null,null,1.3,"Unearned premium MLR Reporting year",null,null,null,null,null,null,{"$f":"85*L22/(L22+N22)","v":47.455157569620283},null,{"$f":"85*N22/(L22+N22)","v":37.544842430379724}]
[null,null,1.4,"Premium balances written off"]
[]
[null,"2.","Claims:"]
[null,null,2.1,"Claims Paid"]
[null,null,null,"2.1a  Claims paid during the MLR reporting year regardless of incurred date",null,null,null,null,null,null,{"$f":"198856*L30/(L30+N30)","v":102697.50694688752},null,{"$f":"198856*N30/(L30+N30)","v":96158.493053112485}]
[null,null,null,"2.1b  Claims incurred only during the MLR reporting year, paid through 3/31 of the following year",null,null,null,null,null,null,null,95897.462114182199,null,89791.424530750795]
[null,null,2.2000000000000002,"Direct claim liability"]
[null,null,null,"2.2a Liability as of 12/31 of MLR reporting year for all claims regardless of incurred date",null,null,null,null,null,null,{"$f":"43395*L30/(L30+N30)","v":22410.982389066379},null,{"$f":"43395*N30/(L30+N30)","v":20984.017610933621}]
[null,null,null,"2.2b Liability for claims incurred only during the MLR reporting year, calculated as of 3/31 of the following year"]
[null,null,2.2999999999999998,"Direct claim liability prior year",null,null,null,null,null,null,34463,null,29149]
[null,null,2.4,"Direct claim reserves"]
[null,null,null,"2.4a Reserves as of 12/31 of MLR reporting year for all claims regardless of incurred date"]
[null,null,null,"2.4b Reserves for claims incurred only during the MLR reporting year, calculated as of 3/31 of the following year",null,null,null,null,null,null,null,2233.9960000000001,null,1964.8332]
[null,null,2.5,"Direct claim reserves prior year"]
[null,null,2.6,"Experience rating refunds (rate credits) paid"]
[null,null,null,"2.6a Experience rating refunds, with all incurred dates, paid in the MLR reporting year"]
[null,null,null,"2.6b Experience rating refunds associated with premium earned only in the reporting year and paid through 3/31 of the following year"]
[null,null,2.7,"Reserve for experience rating refunds (rate credits)"]
[null,null,null,"2.7a Reserved in MLR reporting year regardless of incurred date"]
[null,null,null,"2.7b Reserves specific to the MLR reporting year through 3/31 of the following year"]
[null,null,"2.8","Reserve for experience rating refunds (rate credits) prior year"]
[null,null,2.9,"Incurred dental incentive pool and bonuses"]
[null,null,null,"2.9a  Paid dental incentive pools and bonuses MLR Reporting year"]
[null,null,null,"2.9b  Accrued dental incentive pools and bonuses MLR Reporting year"]
[null,null,null,"2.9c  Accrued dental incentive pools and bonuses prior year"]
[null,null,"2.10","Contingent benefit and lawsuit reserves"]
[null,null,"2.11","Total incurred claims ",{"$f":"E29+E32-E34+E36-E38+E40+E43-E45+E47+E48-E49+E50","v":0},{"$f":"F30+F33+F37+F41+F44+F47+F48+F50","v":0},{"$f":"G29+G32-G34+G36-G38+G40+G43-G45+G47+G48-G49+G50","v":0},{"$f":"H30+H33+H37+H41+H44+H47+H48+H50","v":0},{"$f":"I29+I32-I34+I36-I38+I40+I43-I45+I47+I48-I49+I50","v":0},{"$f":"J30+J33+J37+J41+J44+J47+J48+J50","v":0},{"$f":"K29+K32-K34+K36-K38+K40+K43-K45+K47+K48-K49+K50","v":90645.489335953898},{"$f":"L30+L33+L37+L41+L44+L47+L48+L50","v":98131.458114182198},{"$f":"M29+M32-M34+M36-M38+M40+M43-M45+M47+M48-M49+M50","v":87993.510664046102},{"$f":"N30+N33+N37+N41+N44+N47+N48+N50","v":91756.257730750789},{"$f":"O29+O32-O34+O36-O38+O40+O43-O45+O47+O48-O49+O50","v":0},{"$f":"P30+P33+P37+P41+P44+P47+P48+P50","v":0}]
[]
[]
[null,null,"Cell Keys:"]
[null,null,null,"Blank cells require input from Health plan or Health insurer"]
[null,null,null,"Grey cells require no data input"]
[null,null,null,"Pink cells require no data input - locked down"]
[null,null,null,"Blue cells: computed cell (formula cell)"]

{"sheet":"Pt 3 Expense Allocation","index":3,"n_rows":87,"n_cols":4,"rows_kept":87,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care/Department of Insurance"]
[null,"Medical Loss Ratio Reporting Form: Dental Coverage "]
[null,"Part 3 - Expense Allocation"]
[]
[null,"Health Plan ID"]
[null,{"$f":"'Cover Page'!C7","v":0},null,"Part 3"]
[null,"Legal Name"]
[null,{"$f":"'Cover Page'!C8","v":"Madison National Life Insurance Company, Inc."}]
[null,"dBA"]
[null,{"$f":"'Cover Page'!C9","v":0}]
[null,"MLR Reporting Year"]
[null,{"$f":"'Cover Page'!C6","v":"2019"}]
[]
[]
[null,"Description of Expense Element (by Type)","NEW","Detailed Description of Expense Allocation Methods"]
[null,1,2,3]
[null,"1.  Incurred Claims"]
[null,"Includes obligations for services rendered per the policy contract.",null,"Used Company records of paid claims and reserves by state.  Reserves were calculated using"]
[null,"Incurred claims includes payments for services already rendered",null,"completion ratios developed throught traditional completion ratio methods.  Reserves are allocated"]
[null,"and paid (paid claims) plus reserves.   Reserves cover liabilities",null,"down to the policyholder which allows reserves to be allocated by state."]
[null,"for services already rendered and received by the Company, but "]
[null,"not paid, and those services rendered but not yet received by the "]
[null,"Company."]
[null,"2.  Federal and State Taxes and Licensing or Regulatory Fees"]
[null,"2.a Federal taxes and assessments"]
[null,"Federal Taxes",null,"Applied overall company federal tax rate to California Dental Net Income from Operations before tax."]
[]
[]
[]
[]
[]
[null,"2.b State insurance, premium and other taxes"]
[null,"Premium and other taxes",null,"Applied taxes based upon percentage of CA Dental Premiums"]
[]
[]
[]
[]
[]
[null,"2.c Community benefit expenditures "]
[]
[]
[]
[]
[]
[]
[null,"2.d Regulatory authority licenses and fees"]
[]
[]
[]
[]
[]
[]
[null,"3.  Non-Claims costs"]
[null,"3.a Direct sales salaries and benefits"]
[]
[]
[]
[]
[]
[]
[null,"3.b Agents and brokers fees and commissions"]
[null,"Agent Commissions",null,"Based upon CA percentage of Dental commissions."]
[]
[]
[]
[]
[]
[null,"3.c Other taxes"]
[]
[]
[]
[]
[]
[]
[null,"3.d Other general and administrative expenses"]
[null,"Other General and Administrative expenses",null,"Expenses allocated by lines of business based upon employee time studies and to California based upon percentage of California premiums."]
[]
[]
[]
[]
[]
[]
[null,"Cell Keys:"]
[null,"Blank cells require input from Health plan or Health insurer"]
[null,"Grey cells require no data input "]
[null,"Pink cells require no data input - locked down"]
[null,"Blue cells: computed cell (formula cell)"]

{"sheet":"Pt 4 MLR Calculation","index":4,"n_rows":41,"n_cols":28,"rows_kept":41,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care/Department of Insurance"]
[null,"Medical Loss Ratio Reporting Form: Dental Coverage ",null,null,null,"",null,null,"",null,"",null,null,null,null,null,null,"",null,null,"",null,""]
[null,"Part 4 - MLR Calculation"]
[]
[null,"Health Plan ID"]
[null,null,null,{"$f":"'Cover Page'!C7","v":0},null,"Part 4"]
[null,"Legal Name"]
[null,null,null,{"$f":"'Cover Page'!C8","v":"Madison National Life Insurance Company, Inc."}]
[null,"dBA"]
[null,null,null,{"$f":"'Cover Page'!C9","v":0}]
[null,"MLR Reporting Year"]
[null,null,null,{"$f":"'Cover Page'!C6","v":"2019"}]
[]
[]
[null,null,null,null,null,null,null,null,null,"Health Insurance Coverage",null,null,null,null,null,null,null,null,null,null,null,"Health Insurance Coverage"]
[null,null,null,null,null,null,null,null,null,"DHMO Products",null,null,null,null,null,null,null,null,null,null,null,"DPPO & Indemnity Products"]
[null,null,null,null,null,"Individual",null,null,null,"Small Group",null,null,null,"Large Group",null,null,null,"Individual",null,null,null,"Small Group",null,null,null,"Large Group"]
[null,null,null,"Part 4\nNOTE: REFER TO MLR INSTRUCTIONS FOR IMPORTANT ","PY2","PY1","CY","Total ","PY2","PY1","CY","Total","PY2","PY1","CY","Total","PY2","PY1","CY","Total ","PY2","PY1","CY","Total","PY2","PY1","CY","Total"]
[null,null,null,"INFORMATION ABOUT COMPLETING EACH COLUMN AND ROW.",1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]
[null,"1.","Medical Loss Ratio Numerator"]
[null,null,1.1000000000000001,"Adjusted incurred claims as reported on MLR Form for prior year(s)",null,null,null,null,null,null,null,null,null,null,null,null,170715.389683902,132735.68319999901,null,null,220452.64203799999,134691.18549999999]
[null,null,1.2,"Adjusted incurred claims as of 3/31 of the year following the MLR reporting year (Part 1 Line 2.1)",null,null,{"$f":"'Pt 1 Summary of Data'!F24","v":0},{"$f":"SUM(E22:G22)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!H24","v":0},{"$f":"SUM(I22:K22)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!J24","v":0},{"$f":"SUM(M22:O22)","v":0},198379.16850601099,147814.19311116001,{"$f":"'Pt 1 Summary of Data'!L24","v":98131.458114182198},{"$f":"SUM(Q22:S22)","v":444324.8197313532},230339.33697440699,138976.44764752299,{"$f":"'Pt 1 Summary of Data'!N24","v":91756.257730750789},{"$f":"SUM(U22:W22)","v":461072.04235268076},null,null,{"$f":"'Pt 1 Summary of Data'!P24","v":0},{"$f":"SUM(Y22:AA22)","v":0}]
[null,null,1.3,"MLR numerator (Line 1.2)",{"$f":"SUM(E$22)","v":0},{"$f":"SUM(F$22)","v":0},{"$f":"SUM(G$22:G$22)","v":0},{"$f":"SUM(E23:G23)","v":0},{"$f":"SUM(I$22:I$22)","v":0},{"$f":"SUM(J$22:J$22)","v":0},{"$f":"SUM(K$22:K$22)","v":0},{"$f":"SUM(I23:K23)","v":0},{"$f":"SUM(M$22:M$22)","v":0},{"$f":"SUM(N$22:N$22)","v":0},{"$f":"SUM(O$22:O$22)","v":0},{"$f":"SUM(M23:O23)","v":0},{"$f":"SUM(Q$22:Q$22)","v":198379.16850601099},{"$f":"SUM(R$22:R$22)","v":147814.19311116001},{"$f":"SUM(S$22:S$22)","v":98131.458114182198},{"$f":"SUM(Q23:S23)","v":444324.8197313532},{"$f":"SUM(U$22:U$22)","v":230339.33697440699},{"$f":"SUM(V$22:V$22)","v":138976.44764752299},{"$f":"SUM(W$22:W$22)","v":91756.257730750789},{"$f":"SUM(U23:W23)","v":461072.04235268076},{"$f":"SUM(Y$22:Y$22)","v":0},{"$f":"SUM(Z$22:Z$22)","v":0},{"$f":"SUM(AA$22:AA$22)","v":0},{"$f":"SUM(Y23:AA23)","v":0}]
[null,null,null,"  "]
[null,"2.","Medical Loss Ratio Denominator"]
[null,null,2.1,"Premium earned (Part 1 Line 1.1)",null,null,{"$f":"'Pt 1 Summary of Data'!F21","v":0},{"$f":"SUM(E26:G26)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!H21","v":0},{"$f":"SUM(I26:K26)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!J21","v":0},{"$f":"SUM(M26:O26)","v":0},508201.23580000002,466858.9939,{"$f":"'Pt 1 Summary of Data'!L21","v":318028.75},{"$f":"SUM(Q26:S26)","v":1293088.9797},544638.42390000005,340193.47879999998,{"$f":"'Pt 1 Summary of Data'!N21","v":251613.1},{"$f":"SUM(U26:W26)","v":1136445.0027000001},null,null,{"$f":"'Pt 1 Summary of Data'!P21","v":0},{"$f":"SUM(Y26:AA26)","v":0}]
[null,null,2.2000000000000002,"Federal and State taxes and licensing or regulatory fees ( Part 1 Line 3.4)",null,null,{"$f":"'Pt 1 Summary of Data'!F35","v":0},{"$f":"SUM(E27:G27)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!H35","v":0},{"$f":"SUM(I27:K27)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!J35","v":0},{"$f":"SUM(M27:O27)","v":0},{"$f":"Support!E52+Support!E54","v":92225.160989035096},{"$f":"Support!E38+Support!E40","v":68892.011675787711},{"$f":"'Pt 1 Summary of Data'!L35","v":33894.597169855166},{"$f":"SUM(Q27:S27)","v":195011.76983467798},{"$f":"Support!F52+Support!F54","v":193271.39546120164},{"$f":"Support!F38+Support!F40","v":57688.801178603237},{"$f":"'Pt 1 Summary of Data'!N35","v":20512.37370967451},{"$f":"SUM(U27:W27)","v":271472.57034947939},null,null,{"$f":"'Pt 1 Summary of Data'!P35","v":0},{"$f":"SUM(Y27:AA27)","v":0}]
[null,null,2.2999999999999998,"MLR Denominator (Line 2.1 - Line 2.2) ",{"$f":"E$26-E$27","v":0},0,0,{"$f":"H$26-H$27","v":0},{"$f":"I$26-I$27","v":0},{"$f":"J$26-J$27","v":0},0,{"$f":"L$26-L$27","v":0},0,0,0,{"$f":"P$26-P$27","v":0},415976.07481096493,397966.98222421226,284134.15283014486,{"$f":"T$26-T$27","v":1098077.2098653221},351367.02843879838,282504.67762139672,231100.72629032549,{"$f":"X$26-X$27","v":864972.43235052074},0,0,0,{"$f":"AB$26-AB$27","v":0}]
[]
[null,"3.",3.1,"Life-years (Part 1 Line 5.3)",null,null,{"$f":"'Pt 1 Summary of Data'!F49","v":0},{"$f":"SUM(E30:G30)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!H49","v":0},{"$f":"SUM(I30:K30)","v":0},null,null,{"$f":"'Pt 1 Summary of Data'!J49","v":0},{"$f":"SUM(M30:O30)","v":0},944.59300974999996,861.35311641666704,{"$f":"'Pt 1 Summary of Data'!L49","v":526.75},{"$f":"SUM(Q30:S30)","v":2332.696126166667},542.39532941666698,333.16206275000002,{"$f":"'Pt 1 Summary of Data'!N49","v":229.58333333333334},{"$f":"SUM(U30:W30)","v":1105.1407255000004},null,null,{"$f":"'Pt 1 Summary of Data'!P49","v":0},{"$f":"SUM(Y30:AA30)","v":0}]
[]
[null,"4.",null,"MLR Calculation (for Health plans or health insurers with at least 1,000 life years in the Total column of Line 3.1)"]
[null,null,4.0999999999999996,"MLR",null,null,null,{"$f":"IF(H30<1000,\"Not Required to Calculate\",H23/H28)","v":"Not Required to Calculate"},null,null,null,{"$f":"IF(L30<1000,\"Not Required to Calculate\",L23/L28)","v":"Not Required to Calculate"},null,null,null,{"$f":"IF(P30<1000,\"Not Required to Calculate\",P23/P28)","v":"Not Required to Calculate"},null,null,null,{"$f":"IF(T30<1000,\"Not Required to Calculate\",T23/T28)","v":0.40463895957357054},null,null,null,{"$f":"IF(X30<1000,\"Not Required to Calculate\",X23/X28)","v":0.53304825114453624},null,null,null,{"$f":"IF(AB30<1000,\"Not Required to Calculate\",AB23/AB28)","v":"Not Required to Calculate"}]
[]
[]
[]
[null,null,"Cell Keys:"]
[null,null,null,"Blank cells require input from Health plan or Health insurer"]
[null,null,null,"Grey cells require no data input "]
[null,null,null,"Pink cells require no data input - locked down"]
[null,null,null,"Blue cells: computed cell (formula cell)"]

{"sheet":"Pt 5 Additional Responses","index":5,"n_rows":49,"n_cols":3,"rows_kept":49,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care/Department of Insurance"]
[null,"Medical Loss Ratio Reporting Form: Dental Coverage "]
[null,"Part 5 - Additional Responses"]
[]
[null,"Health Plan ID"]
[null,{"$f":"'Cover Page'!C7","v":0}]
[null,"Legal Name","Part 5"]
[null,{"$f":"'Cover Page'!C8","v":"Madison National Life Insurance Company, Inc."}]
[null,"dBA"]
[null,{"$f":"'Cover Page'!C9","v":0}]
[null,"MLR Reporting Year"]
[null,{"$f":"'Cover Page'!C6","v":"2019"}]
[]
[]
[]
[null,null,"Tax Rate "]
[null,"1. If a health plan or health insurer uses the hightest premium tax rate in the State, the health plan or health insurer must report applicabe highest State health premium tax rate."]
[null,"2. If the health plan or health insurer included deferred experience for prior year and excluded deferred experience for current year, provide the total direct written premium and total incurred claims for the deferred experience by market."]
[null,"Deferred experience for prior year"]
[null,"Deferred experience for current year"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"3. If the health plan or health insurer novated any business in the MLR reporting year effective during the reporting year provide the name of the entity to whom the business was sold or transferred and the date of the sale or transfer."]
[null,"Name of Entity to whom business was sold or transferred","Effective date of sale or transfer"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"Cell Keys:"]
[null,"Blank cells require input from Health plan or Health insurer"]
[null,"Grey cells require no data input "]
[null,"Pink cells require no data input - locked down"]
[null,"Blue cells: computed cell (formula cell)"]

{"sheet":"Attestation","index":6,"n_rows":27,"n_cols":4,"rows_kept":27,"cut":false,"hidden":false,"merged":[]}
[null,"Department of Managed Health Care"]
[null,"Medical Loss Ratio Reporting Form: Dental Coverage "]
[null,"Attestation"]
[]
[null,"Health Plan ID"]
[null,{"$f":"'Cover Page'!C7","v":0}]
[null,"Legal Name"]
[null,{"$f":"'Cover Page'!C8","v":"Madison National Life Insurance Company, Inc."},null,"Attestation"]
[null,"dBA"]
[null,{"$f":"'Cover Page'!C9","v":0}]
[null,"MLR Reporting Year"]
[null,{"$f":"'Cover Page'!C6","v":"2019"}]
[]
[]
[]
[]
[null,"Attestation Statement"]
[null,"The officers of this reporting Health plan being duly sworn, each attest that he/she is the described officer of the reporting Health plan, and that this MLR Reporting Form, the Company/Health plan Associations, and any supplemental submission that the Health plan includes are full and true statements of all the elements included therein for the MLR reporting year stated above, and that the MLR Reporting Form has been completed in accordance with the Department of Managed Health Care’s guidance and reporting instructions, according to the best of his/her information, knowledge and belief.  Furthermore, the scope of this attestation by the described officer includes any related electronic filings and postings for the MLR reporting year stated above and which are required by Department of Managed Health Care."]
[]
[]
[]
[]
[null,"Chief Executive Officer/President"]
[]
[]
[]
[null,"Chief Financial Officer"]

{"sheet":"Support","index":7,"n_rows":55,"n_cols":9,"rows_kept":55,"cut":false,"hidden":false,"merged":[]}
["Statutory Byline",null,null,null,"12/31/19",null,null,null,"Updated 6/24/20"]
["2019","Dental LOB",null,null,"Byline for state of"]
[null,"(from Stat byline)",null,null,"California",null,"Ind","Sm Grp"]
["Premiums",7910154,null,null,574084,null,{"$f":"'Pt 2 Premium and Claims'!L22","v":318028.75},{"$f":"'Pt 2 Premium and Claims'!N22","v":251613.1},"Eric Galles"]
["Inv Income",{"$f":"23085+1142+3108","v":27335},{"$f":"B5/B4","v":3.4556849335676651E-3},null,{"$f":"1675+83+226","v":1984},null,{"$f":"$G$19*C5","v":1923.6647260898503},{"$f":"$H$19*C5","v":1175.6014791871307}]
["Claims",3545095,{"$f":"B6/$B$19","v":0.3214714892808227},null,178638,null,{"$f":"'Pt 2 Premium and Claims'!L51","v":98131.458114182198},{"$f":"'Pt 2 Premium and Claims'!N51","v":91756.257730750789},"Eric Galles"]
["Commissions",1267784,{"$f":"B7/$B$19","v":0.11496346658309539},null,92010,null,{"$f":"G4*C7","v":36561.687573088595},{"$f":"$H$19*C7","v":39109.821631810766}]
["Gen Expenses",1979316,{"$f":"B8/$B$19","v":0.17948564489170554},null,143650,null,{"$f":"G4*C8","v":57081.595287853001},{"$f":"$H$19*C8","v":61059.845930370757}]
["Taxes, Licenses, Fees",324557,{"$f":"B9/$B$19","v":2.9431037009308911E-2},null,23555,null,{"$f":"G4*C9","v":9359.9159112742509},{"$f":"$H$19*C9","v":10012.246864888346}]
["  Net",{"$f":"B4+B5-SUM(B6:B9)","v":820737},{"$f":"B10/$B$19","v":7.4424957779093248E-2},null,{"$f":"E4+E5-SUM(E6:E9)","v":138215},null,{"$f":"G4+G5-SUM(G6:G9)","v":118817.7578396918},{"$f":"H4+H5-SUM(H6:H9)","v":50850.529321366485}]
["Fed Taxes",169474,{"$f":"B11/B10","v":0.20649002055469656},null,28540,null,{"$f":"G10*C11","v":24534.681258580917},{"$f":"H10*C11","v":10500.126844786166}]
["  Net Income",{"$f":"B10-B11","v":651263},{"$f":"B12/$B$19","v":5.9056946717505859E-2},null,{"$f":"E10-E11","v":109675},null,{"$f":"G10-G11","v":94283.076581110887},{"$f":"H10-H11","v":40350.402476580319}]
[]
[]
[]
["Statutory Byline",null,null,null,"12/31/18"]
["2018","Dental LOB",null,null,"Byline for state of"]
[null,"(from Stat byline)",null,null,"California",null,"Ind","Sm Grp"]
["Premiums",11027712,null,null,814167,null,556666.69938681298,340193.47879999998,"Eric Galles"]
["Inv Income",17970,{"$f":"B20/B19","v":1.629531130301553E-3},null,1327,null,907.10571585302819,554.35586403018135]
["Claims",4745770,{"$f":"B21/$B$19","v":0.43034946868398449},null,262964,null,158643.27993583403,134691.18549999999,"Eric Galles"]
["Commissions",1715806,{"$f":"B22/$B$19","v":0.1555903890126982},null,126677,null,86611.988308008964,52930.835706075093]
["Gen Expenses",2530299,{"$f":"B23/$B$19","v":0.2294491368653806},null,186810,null,127726.69369600453,78057.100077891155]
["Taxes, Licenses, Fees",468525,{"$f":"B24/$B$19","v":4.248614762518281E-2},null,34591,null,23650.623568171399,14453.510361421299]
["  Net",{"$f":"B19+B20-SUM(B21:B24)","v":1585282},{"$f":"B25/$B$19","v":0.14375438894305545},null,{"$f":"E19+E20-SUM(E21:E24)","v":204452},null,160941.21959464712,60615.203018642671]
["Fed Taxes",315642,{"$f":"B26/B25","v":0.19910779280910273},null,40708,null,32044.651005495303,12068.959283717604]
["  Net Income",{"$f":"B25-B26","v":1269640},{"$f":"B27/$B$19","v":0.11513176985398241},null,{"$f":"E25-E26","v":163744},null,128896.56858915181,48546.243734925069]
[]
[]
["Statutory Byline"]
["2017","Dental LOB"]
[null,"(from Stat byline)",null,null,"Ind","Sm Grp"]
["Premiums",15182845,null,null,507231,544862]
["Inv Income",{"$f":"46771+2761","v":49532},{"$f":"B34/B33","v":3.2623661770899985E-3},null,1654.7732583715369,1777.5393599816107]
["Claims",6014080,{"$f":"B35/$B$33","v":0.3961102151803565},null,170269,222707]
["Commissions",2200130,{"$f":"B36/$B$33","v":0.1449089416377497},null,73502.307375857417,78955.375758627575]
["Gen Expenses",3532757,{"$f":"B37/$B$33","v":0.23268083155693153},null,118022.93087145394,126778.94324377282]
["Taxes, Licenses, Fees",436564,{"$f":"B38/$B$33","v":2.8753767821511712E-2},null,14584.802405873208,15666.835442764515]
["  Net",{"$f":"B33+B34-SUM(B35:B38)","v":3048846},{"$f":"B39/$B$33","v":0.20080860998054054},null,132506.73260518693,102531.38491481676]
["Fed Taxes",1249554,{"$f":"B40/B39","v":0.40984490525267592},null,54307.2092699145,42021.965735838719]
["  Net Income",{"$f":"B39-B40","v":1799292},{"$f":"B41/$B$33","v":0.11850822424914435},null,78199.523335272432,60509.419178978045]
[]
[]
["Statutory Byline"]
["2016","Dental LOB"]
[null,"(from Stat byline)",null,null,"Ind","Sm Grp"]
["Premiums",18780550,null,null,558874.46621471399,1387886]
["Inv Income",52460,2.7933154247346322E-3,null,1561.1126669678947,3876.8033715732499]
["Claims",10375065,0.6833412973655465,null,200258.326799998,611300]
["Commissions",2917174,0.19213619054926795,null,107380.0109337507,266663.12895666127]
["Gen Expenses",3552466,0.23397894136441491,null,365.26748916772641,907.0903487587035]
["Taxes, Licenses, Fees",665120,4.3807336503797541E-2,null,8772.7839098149707,26779.424804771435]
["  Net",1323185,8.7150003836566861E-2,null,243659.18974895048,486113.15926138184]
["Fed Taxes",453186,0.34249632515483475,null,83452.377079220125,166491.9706564302]
["  Net Income",869999,null,null,160206.81266973034,319621.1886049516]

{"sheet":"Instructions","index":8,"n_rows":24,"n_cols":1,"rows_kept":24,"cut":false,"hidden":false,"merged":[]}
["Instructions for filling out form in order of completion:"]
[]
["Part 2:"]
["Eric Galles filled out green boxes for 2017 data trued up as of 3/31/18 col L and N"]
["I filled in all data for 12/31/17 columns K and M based upon YE 2017 Dental data from \"Group A&H 2017 Premium\" and \"Group A&H 2017 Claim\" reports"]
["Also, I pulled reserve data from the financials for the Dental lob."]
["I allocated premiums, claims, and reserves based upon Eric's allocation in col L and N."]
[]
["Part 1:"]
["Premium and Claims data references Part 2."]
["Federal Taxes, Prem Taxes, Comm, Expenses for Col L & N for 3/31/18 come from \"Support\" tab which comes from Stat byline Dental Column allocated to Ind & Sm Grp"]
["Federal Taxes, Prem Taxes, Comm, Expenses for Col K & M for 12/31/17 are allocations based upon data in Col L & N."]
["Data for Lines 5 come from Eric Galles with the number from Line 5.1 Covered Lives equaling what we have in support from Policy Inforce Summary file."]
["Fill in Net Investment Income on Line 6 from Dental column from Stat byline adjusted for % for state of CA."]
[]
["Part 3:"]
["This tab reflects how I allocated various expenses to the state of California."]
[]
["Part 4:"]
["Current Year pulls in data from other parts of file."]
["Prior Year data comes from Eric Galles"]
[]
["Part 5:"]
["Nothing to complete."]