5-SCBOCC ExpRpt FMR BCBSFL Medical 2025.12 (1).pdf
PDF 547 KB Posted
- Attached to
- Group Medical Benefits
- Solicitation number
- 2026-10
- Issued by
- Seminole County, Florida
About this file
This is a Financial Monitoring Report prepared by Florida Blue for the Suwannee County Board of County Commissioners covering medical and pharmacy claims paid between January 1, 2025, and December 31, 2025. The report provides a comprehensive analysis of health insurance claims for employees and eligible retirees of Suwannee County and its constitutional offices, including the Sheriff, Tax Collector, Property Appraiser, Clerk of Courts, and Supervisor of Elections. The document tracks claims data across multiple plan options under the Florida Blue carrier, including BlueOptions plans 03160/61 and 03559, and BlueCare Plan 60, with an average monthly enrollment of 415 subscribers throughout the reporting period. The plan year runs from October 1, 2025, through September 30, 2026.
The report reveals significant cost concerns for the current plan year. Through December 2025, gross medical and pharmacy claims totaled $1,328,640, representing a loss ratio of 118.1 percent against paid premiums of $1,125,350, indicating claims exceeded premiums by thirteen percent. This represents a 59.3 percent increase in claims per employee per month (PEPM) compared to the prior year, rising from $670.55 to $1,068.04 PEPM, while premium PEPM increased only modestly from $834.83 to $904.62. The December 2025 month alone generated $678,816 in claims or $1,647.61 PEPM, significantly above the target loss ratio of eighty-five percent. The analysis identified six large claimants exceeding the $215,000 pooling point, with claims ranging from $107,962 to $351,979 and totaling $1,113,373 in combined medical and pharmacy costs. The substantial increase in claims and unfavorable loss ratio suggests potential cost pressures requiring attention to plan design, utilization patterns, or carrier negotiations for the remainder of the plan year.
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This analysis is for illustrative purposes only, and is not a guarantee of future expenses, claims costs, managed care savings, etc. There are many variables that can affect future health care costs including utilization patterns, catastrophic claims, changes in plan design, health care trend increases, etc. This analysis does not amend, extend, or alter the coverage provided by the actual insurance policies and contracts. Please see your policy or contact us for specific information or further details in this regard.
Medical: Paid Between January 1, 2025 - December 31, 2025
CLAIM ANALYSIS
PREPARED EXCLUSIVELY FOR:
Suwannee County Board of County Commissioners
Presented by
Financial Monitoring Report - Suwannee County Board of County Commissioners
Executive Analysis
Paid Between January 31, 2025 - December 31, 2025
Carrier: Florida Blue
Fully-Insured
1) The gross Medical and Pharmacy claims for the month of December is $678,816 or $1,647.61 PEPM
2) The Plan Year to Date gross Medical and Pharmacy claims through December is $1,328,640 or $1,068.04 PEPM
3) The Plan Year to Date Paid Premium is $1,125,350 or $904.62 PEPM
4) The Plan Year to Date Loss Ratio is 118.1%
5) 2 Individuals exceeded $215,000 Pooling Point within the most recent 12 months
Executive Analysis
Historical Claim Summary
Reporting Through December 31, 2025
Total Medical/Rx Claims
Month 2023 / 2024 2024 / 2025 2025 / 2026
October $215,139 $197,150 $267,656
November $183,970 $212,020 $382,168
December $313,579 $203,318 $678,816
January $210,387 $410,358 $0
February $211,096 $221,859 $0
March $389,389 $212,691 $0
April $275,966 $372,362 $0
May $315,143 $256,832 $0
June $268,937 $265,393 $0
July $447,597 $410,624 $0
August $827,601 $288,575 $0
September $290,346 $288,149 $0
Gross Claims $3,949,149 $3,339,330 $1,328,640
Average Monthly Enrollment 414 415 415
Claims PEPM $795.88 $670.55 $1,068.04
% Increase/Decrease from Prior Year NA -15.7% 59.3%
Premiums $3,978,550 $4,157,431 $1,125,350
Premium PEPM $801.80 $834.83 $904.62
Premium vs. Claims 99.3% 80.3% 118.1%
2023 / 2024 2024 / 2025 2025 / 2026
Premiums $3,978,550 $4,157,431 $1,125,350
Gross Claims $3,949,149 $3,339,330 $1,328,640
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
Premium vs. Claims by Plan Year
2023 / 2024 2024 / 2025 2025 / 2026
Premium PEPM $801.80 $834.83 $904.62
Claims PEPM $795.88 $670.55 $1,068.04
$0.00
$200.00
$400.00
$600.00
$800.00
$1,000.00
$1,200.00
Premium vs. Claims PEPM
Medical Summary - All Plans
Paid Between January 31, 2025 - December 31, 2025
Carrier: Florida Blue
Plan Year: 10/1/2025 - 9/30/2026
Paid Month Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Total PEPM Total PEPM
Enrollment
Subscribers 422 419 415 409 408 409 419 414 412 416 416 412 1,244 415 4,971 414
Employee Only 400 398 394 390 389 390 397 391 390 395 395 389 1,179 393 4,718 393
Employee + Spouse 11 10 10 9 9 9 10 10 10 10 10 11 31 10 119 10
Employee + Child(ren) 10 10 10 10 10 10 12 13 12 11 11 12 34 11 131 11
Employee + Family 1 1 1 0 0 0 0 0 0 0 0 0 0 0 3 0
Members 457 453 449 440 439 440 454 450 445 448 445 443 1,336 445 5,363 447
Contract Size 1.08 1.08 1.08 1.08 1.08 1.08 1.08 1.09 1.08 1.08 1.07 1.08
Claim Payments
Medical Claims $330,779 $134,045 $130,991 $290,255 $166,236 $187,511 $298,238 $195,184 $202,591 $154,680 $317,119 $562,785 $1,034,584 $831.66 $2,970,413 $597.55
Rx Claims $76,177 $84,004 $78,120 $78,576 $87,024 $74,082 $108,370 $89,481 $81,653 $108,873 $61,296 $111,771 $281,940 $226.64 $1,039,425 $209.10
Capitation $1,762 $2,181 $1,789 $1,740 $1,761 $1,746 $1,973 $1,856 $1,886 $1,925 $1,872 $1,820 $5,618 $4.52 $22,311 $4.49
Value Base $1,641 $1,629 $1,792 $1,792 $1,811 $2,054 $2,044 $2,054 $2,020 $2,178 $1,881 $2,439 $6,498 $5.22 $23,332 $4.69
Total Claim Payments $410,358 $221,859 $212,691 $372,362 $256,832 $265,393 $410,624 $288,575 $288,149 $267,656 $382,168 $678,816 $1,328,640 $1,068.04 $4,055,482 $815.83
Premium $351,697 $350,654 $351,083 $344,899 $334,560 $337,332 $348,604 $349,453 $341,919 $376,107 $371,164 $378,078 $1,125,350 $904.62 $4,235,549 $852.05
Premium vs. Claims 116.7% 63.3% 60.6% 108.0% 76.8% 78.7% 117.8% 82.6% 84.3% 71.2% 103.0% 179.5%
Employee Contributions $14,317 $13,738 $13,738 $11,746 $11,746 $11,746 $13,713 $14,046 $13,302 $12,843 $13,328 $14,196 $40,367 $32.45 $158,460 $31.88
Employer Cost $337,380 $336,915 $337,345 $333,152 $322,814 $325,586 $334,891 $335,407 $328,617 $363,264 $357,836 $363,882 $1,084,983 $872.17 $4,077,089 $820.17
Rolling 12
1.08
95.7%
Current Policy
1.07
118.1%
78%
21%
0%
1%
Combined Plan Expenses
Medical Claims Rx Claims Capitation Value Base
117%
63% 61%
108%
77% 79%
118%
83% 84%
71%
103%
180%
96%
0%
20%
40%
60%
80%
100%
120%
140%
160%
180%
200%
Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Rolling 12
Loss Ratio Comparison
Premium vs. Claims Target Loss Ratio (85%)
Medical Summary - BlueOptions 03160/61
Paid Between January 31, 2025 - December 31, 2025
Carrier: Florida Blue
Plan Year: 10/1/2025 - 9/30/2026
Paid Month Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Total PEPM Total PEPM
Enrollment
Subscribers 79 79 77 77 77 77 81 80 80 77 76 77 230 77 937 78
Employee Only 67 68 66 67 67 67 70 68 68 65 65 64 194 65 802 67
Employee + Spouse 5 4 4 4 4 4 4 4 4 4 4 5 13 4 50 4
Employee + Child(ren) 6 6 6 6 6 6 7 8 8 8 7 8 23 8 82 7
Employee + Family 1 1 1 0 0 0 0 0 0 0 0 0 0 0 3 0
Members 100 99 97 95 95 95 100 100 100 97 92 95 284 95 1,165 97
Contract Size 1.27 1.25 1.26 1.23 1.23 1.23 1.23 1.25 1.25 1.26 1.21 1.23
Claim Payments
Medical Claims $117,139 $15,297 $26,460 $47,741 $37,779 $5,523 $36,273 $9,300 $35,577 $11,777 $10,248 $88,210 $110,236 $479.29 $441,327 $471.00
Rx Claims $3,386 $1,145 $5,346 $3,353 $4,365 $9,337 $5,403 $8,786 $3,589 $5,666 $4,851 $2,609 $13,126 $57.07 $57,836 $61.72
Capitation $40 $41 $39 $37 $38 $38 $38 $42 $40 $39 $37 $37 $113 $0.49 $466 $0.50
Value Base $204 $179 $189 $179 $160 $219 $209 $189 $188 $198 $0 $153 $351 $1.53 $2,068 $2.21
Total Claim Payments $120,769 $16,662 $32,034 $51,310 $42,342 $15,117 $41,924 $18,318 $39,394 $17,680 $15,136 $91,009 $123,825 $538.37 $501,696 $535.43
Premium $56,639 $56,522 $55,273 $53,385 $54,009 $53,385 $54,634 $57,992 $58,746 $59,125 $58,453 $59,389 $176,967 $769.42 $677,551 $723.11
Premium vs. Claims 213.2% 29.5% 58.0% 96.1% 78.4% 28.3% 76.7% 31.6% 67.1% 29.9% 25.9% 153.2%
Employee Contributions $5,990 $5,411 $5,411 $4,310 $4,310 $4,310 $4,642 $4,975 $4,975 $4,678 $4,377 $5,245 $14,299 $62.17 $58,631 $62.57
Employer Cost $50,649 $51,111 $49,862 $49,075 $49,700 $49,075 $49,991 $53,018 $53,771 $54,446 $54,077 $54,144 $162,667 $707.25 $618,920 $660.53
Current Policy Rolling 12
1.23 1.24
70.0% 74.0%
89%
11%0%
0%
Combined Plan Expenses
Medical Claims Rx Claims Capitation Value Base
213%
29%
58%
96%
78%
28%
77%
32%
67%
30% 26%
153%
74%
0%
50%
100%
150%
200%
250%
Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Rolling 12
Medical Summary - BlueOptions 03559
Paid Between January 31, 2025 - December 31, 2025
Carrier: Florida Blue
Plan Year: 10/1/2025 - 9/30/2026
Paid Month Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Total PEPM Total PEPM
Enrollment
Subscribers 138 137 135 131 130 130 131 129 127 131 135 134 400 133 1,588 132
Employee Only 132 131 129 126 125 125 125 123 121 126 129 128 383 128 1,520 127
Employee + Spouse 3 3 3 2 2 2 3 3 3 3 3 3 9 3 33 3
Employee + Child(ren) 3 3 3 3 3 3 3 3 3 2 3 3 8 3 35 3
Employee + Family 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Members 146 145 143 138 137 137 139 137 135 138 143 142 423 141 1,680 140
Contract Size 1.06 1.06 1.06 1.05 1.05 1.05 1.06 1.06 1.06 1.05 1.06 1.06
Claim Payments
Medical Claims $67,315 $63,020 $67,682 $103,834 $52,983 $47,355 $200,285 $139,515 $97,056 $76,949 $152,533 $404,622 $634,105 $1,585.26 $1,473,149 $927.68
Rx Claims $20,831 $39,913 $22,585 $24,915 $25,276 $18,015 $30,293 $24,626 $19,015 $32,093 $26,168 $30,343 $88,604 $221.51 $314,073 $197.78
Capitation $206 $203 $206 $213 $203 $188 $236 $207 $201 $207 $200 $206 $613 $1.53 $2,476 $1.56
Value Base $289 $281 $311 $302 $283 $419 $419 $429 $426 $446 $426 $510 $1,381 $3.45 $4,539 $2.86
Total Claim Payments $88,641 $103,417 $90,783 $129,263 $78,745 $65,977 $231,233 $164,776 $116,697 $109,695 $179,327 $435,681 $724,703 $1,811.76 $1,794,236 $1,129.87
Premium $119,809 $117,312 $118,145 $119,769 $110,497 $109,665 $114,716 $113,052 $108,891 $121,639 $124,323 $126,792 $372,753 $931.88 $1,404,608 $884.51
Premium vs. Claims 74.0% 88.2% 76.8% 107.9% 71.3% 60.2% 201.6% 145.8% 107.2% 90.2% 144.2% 343.6%
Employee Contributions $4,868 $4,868 $4,868 $3,978 $3,978 $3,978 $4,868 $4,868 $4,868 $4,446 $5,233 $5,233 $14,913 $37.28 $56,056 $35.30
Employer Cost $114,941 $112,444 $113,276 $115,791 $106,519 $105,687 $109,848 $108,183 $104,023 $117,193 $119,089 $121,558 $357,840 $894.60 $1,348,551 $849.21
194.4% 127.7%
Current Policy Rolling 12
1.06 1.06
88%
12%
0% 0%
Combined Plan Expenses
Medical Claims Rx Claims Capitation Value Base
74% 88%
77%
108%
71% 60%
202%
146%
107% 90%
144%
344%
128%
0%
50%
100%
150%
200%
250%
300%
350%
400%
Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Rolling 12
Medical Summary - BlueCare 60
Paid Between January 31, 2025 - December 31, 2025
Carrier: Florida Blue
Plan Year: 10/1/2025 - 9/30/2026
Paid Month Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Total PEPM Total PEPM
Enrollment
Subscribers 205 203 203 201 201 202 207 205 205 208 205 201 614 205 2,446 204
Employee Only 201 199 199 197 197 198 202 200 201 204 201 197 602 201 2,396 200
Employee + Spouse 3 3 3 3 3 3 3 3 3 3 3 3 9 3 36 3
Employee + Child(ren) 1 1 1 1 1 1 2 2 1 1 1 1 3 1 14 1
Employee + Family 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Members 211 209 209 207 207 208 215 213 210 213 210 206 629 210 2,518 210
Contract Size 1.03 1.03 1.03 1.03 1.03 1.03 1.04 1.04 1.02 1.02 1.02 1.02
Claim Payments
Medical Claims $146,324 $55,728 $36,849 $138,681 $75,474 $134,632 $61,680 $46,369 $69,958 $65,953 $154,337 $69,953 $290,243 $472.71 $1,055,938 $431.70
Rx Claims $51,959 $42,946 $50,188 $50,308 $57,383 $46,731 $72,673 $56,069 $59,049 $71,114 $30,277 $78,819 $180,211 $293.50 $667,517 $272.90
Capitation $1,516 $1,937 $1,544 $1,490 $1,520 $1,521 $1,698 $1,608 $1,645 $1,679 $1,635 $1,577 $4,892 $7.97 $19,369 $7.92
Value Base $1,148 $1,170 $1,292 $1,311 $1,367 $1,416 $1,416 $1,436 $1,406 $1,535 $1,455 $1,776 $4,766 $7.76 $16,726 $6.84
Total Claim Payments $200,947 $101,780 $89,873 $191,789 $135,744 $184,299 $137,467 $105,481 $132,057 $140,282 $187,705 $152,125 $480,112 $781.94 $1,759,549 $719.36
Premium $175,249 $176,819 $177,665 $171,745 $170,054 $174,282 $179,255 $178,409 $174,282 $195,344 $188,388 $191,898 $575,630 $937.51 $2,153,390 $880.37
Premium vs. Claims 114.7% 57.6% 50.6% 111.7% 79.8% 105.7% 76.7% 59.1% 75.8% 71.8% 99.6% 79.3%
Employee Contributions $3,459 $3,459 $3,459 $3,459 $3,459 $3,459 $4,203 $4,203 $3,459 $3,718 $3,718 $3,718 $11,155 $18.17 $43,773 $17.90
Employer Cost $171,790 $173,360 $174,206 $168,286 $166,595 $170,823 $175,052 $174,206 $170,823 $191,626 $184,670 $188,180 $564,475 $919.34 $2,109,617 $862.48
83.4% 81.7%
Current Policy Rolling 12
1.02 1.03
60%
38%
1%
1%
Combined Plan Expenses
Medical Claims Rx Claims Capitation Value Base
115%
58% 51%
112%
80%
106%
77%
59%
76% 72%
100%
79% 82%
0%
20%
40%
60%
80%
100%
120%
140%
Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25 Jul-25 Aug-25 Sep-25 Oct-25 Nov-25 Dec-25 Rolling 12
Large Claimants Over $107,500
Paid Between January 31, 2025 - December 31, 2025
Carrier: Florida Blue
Plan Year: 10/1/2025 - 9/30/2026
1 BlueOptions 03559 Subscriber Stenosis Of Larynx $346,235 $5,744 $351,979 $136,979
2 BlueOptions 03559 Subscriber Paroxysmal Atrial Fibrillation $211,401 $8,492 $219,893 $4,893
3 BlueOptions 03559 Subscriber Malignant Neoplasm Of Overlapping Sites Of Left Female Breast $190,879 $4,982 $195,861 $0
4 BlueOptions 03160/61 Subscriber Other Fracture Of Left Lower Leg, Initial Encounter For Closed Fracture $125,088 $29 $125,117 $0
5 BlueOptions 03160/61 Subscriber Other Supraventricular Tachycardia $112,560 $0 $112,561 $0
6 BlueCare 60 Subscriber Pharmacy Rx; Chronic Sinusitis, Unspecified $2,727 $105,235 $107,962 $0
Total: $988,892 $124,481 $1,113,373 $141,872
Medical Paid Pharmacy Paid Amount Over
Pooling $215,000 Claimant Plan Relationship Diagnosis Total Paid Claims
This analysis is for illustrative purposes only, and is not a guarantee of future expenses, claims costs, managed care savings, etc. There are many variables that can affect future health care costs including utilization patterns, catastrophic claims, changes in plan design, health care trend increases, etc. This analysis does not amend, extend, or alter the coverage provided by the actual insurance policies and contracts.
Please see your policy or contact us for specific information or further details in this regard.
File details come from the government source that posted it. Updated .