Attachment 2A. HCCs Sept 2023 - Oct 2024-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_32 PM.xlsx

XLSX spreadsheet 685 KB Posted

Attached to
RFP 26-025-CJ GCPS- Employee Medical, Stop Loss, Dental, Vision, Disability & Voluntary Benefits Coverage
Solicitation number
RFP-115259
Issued by
Frederick County, Virginia

About this file

This is a High Cost Claimant (HCC) analysis report prepared by Anthem Blue Cross and Blue Shield for the Gloucester County School Board covering the period October 2023 through September 2024. The report identifies and segments 37 high-cost claimants with medical and pharmacy claims exceeding $50,000 during the measurement period, representing members enrolled in the school board's health insurance plan. The analysis categorizes claimants by demographic information, benefit package, health conditions, and claim amounts to support utilization review and care management initiatives.

The report details total medical claims of $3,653,816 and pharmacy claims of $2,126,415, aggregating to $5,780,231 across the identified high-cost population. Primary health conditions driving costs include malignant neoplasms (cancer), digestive system disorders, circulatory system conditions, and musculoskeletal conditions. The claimants range in age from birth to 65+ years, with the majority concentrated in the 45-64 age bands. The data is segmented by inpatient, outpatient, and professional medical services, with specialty drug spending representing a significant portion of pharmacy costs at 9,387.2% of total pharmacy spend. The report indicates medical claims paid through the latest data loaded in February 2026, with the analysis run on March 18, 2026, providing current-year utilization data for the school board's health plan management and care coordination efforts.

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Other files

File Type Posted
Addendum 1.pdf PDF
external extract for gloucester co.xlsx XLSX spreadsheet
Attachment T – Vision Top Providers for Disruption Analysis.xlsx XLSX spreadsheet
Attachment M – Long Term Disability Claims History.xlsx XLSX spreadsheet
Attachment 3 Retiree Dental GCPS Addendum Question.xlsx XLSX spreadsheet
Addendum 3 FINAL.pdf PDF
Attachment O – Medical Claim Repricing File for Discount and Disruption Analysis.xlsx XLSX spreadsheet
Attachment 2B. HCCs Oct 2024 - Sept 2025-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_31 PM.xlsx XLSX spreadsheet
Addendum 1.pdf PDF
Attachment V - Hybrid STD Benefit Summary.pdf PDF
external extract for gloucester co.xlsx XLSX spreadsheet
Attachment L – Disability Benefits.pdf PDF
Attachment S – Dental Network Utilization for Disruption Analysis .xlsx XLSX spreadsheet
Gloucester County Repricing Summary 02032026 file.xlsx XLSX spreadsheet
Addendum 2.pdf PDF
Attachment 2C. HCCs Oct 2025 - Feb 2026-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_29 PM.xlsx XLSX spreadsheet
Attachment D – Current census and enrollment for all lines of coverage (including COBRA and Retirees).xlsx XLSX spreadsheet
Attachment J – Dental Claims and enrollment history.xlsx XLSX spreadsheet
Attachment 2. HCCS over 50k Feb 2024 - Jan 2025-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260317 03_43 PM.pdf PDF
Attachment H – Vision Benefits.pdf PDF
Attachment B - Price Proposal.xlsx XLSX spreadsheet
Attachment R – Current and Historical Rates - All Lines.pdf PDF
Attachment W - Hybrid LTD Benefit Summary.pdf PDF
Attachment Q – Pharmacy Questionnaire.docx DOCX document
1B Member and claims oct 2025- Feb 2026.xlsx XLSX spreadsheet
Attachment 1. Mem and Claims Oct 2023 - Sept 2024-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_FIN-01_20260317 03_29 PM (2).xlsx XLSX spreadsheet
Attachment K – Vision Claims and enrollment history.pdf PDF
Attachment U - Supplemental Plan Claims Utilization.pdf PDF
Attachment 1A. Mem and Claims Oct 2024 - Sept 2025-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_FIN-01_20260317 03_28 PM.xlsx XLSX spreadsheet
Attachment P – Pharmacy Claim Repricing & Disruption Analysis - DELETE YELLOW ONCE APPROVED.xlsx XLSX spreadsheet
Gloucester County Repricing Cover Letter 02032026.docx DOCX document
Attachment N – Accident, Critical Illness, Hospital Benefits.pdf PDF
Attachment I – Medical Claims, Enrollment, HCCs.xlsx XLSX spreadsheet
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HCC-01_Visualization

HCC-01_1

High Cost Claimant without Member Name > $50,000
GLOUCESTER COUNTY SCHOOL BOARD | Segmentation: Total Account

Current: Oct 2023 - Sep 2024 • Prior 1: Jan 1111 - Jan 1111 • Prior 2: Jan 1111 - Jan 1111 | Data Set: Medical & Pharmacy | Paid/Incurred: Paid

SegmentationMember DetailsClaim Details
RankGroup IDSubgroupBenefit

Package ID Scrambled Claimant ID Prior Period

HCCAge
BandsRelationshipActive
(Yes/No)Member EngagedPrimary

Health Condition Category Primary Medical Diagnosis Contributing to High Cost Secondary Medical Diagnosis Contributing

to High CostPrimary Medical Diagnosis Claim
AmountSecondary

Medical Diagnosis Claim

AmountAll Other Medical Diagnosis Claim
AmountInpatient

Medical Claim Amount Outpatient Medical Claim Amount Professional Medical Claim Amount Medical Total Claim Amount Percent Specialty Drug Spend under Medical Primary Pharmacy Indication Contributing to High Cost Pharmacy Total Claim Amount Percent Specialty Drug Spend under Pharmacy Total Claim Amount Most Recent Month Medical Claim

AmountMost
Recent Month Pharmacy Claim AmountMedical Claim Amount PMPMPharmacy Claim Amount PMPMTotal Claim Amount PMPM
1L03319L03319~L03319M0016GB791817265N55-64Spouse/PartnerNNNeoplasms - MalignantLymphoid LeukemiaNon-Follicular Lymphoma$780,934$5,362$300$780,934$4,158$1,505$786,5960.0%NA$00.0%$786,596.38$0$0$54.26$0.00$54.26
2L03319L03319~L03319M0016GB791066779N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Of Corpus UteriOther Deforming Dorsopathies$236,902$1,471$1,442$0$235,353$4,462$239,8159,084.9%CANCER$302,6829,724.7%$542,496.51$1,638$24,954$16.54$20.88$37.42
3L03319L03319~L03319M0016GB784189513N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Of BreastSecondary Malignant Neoplasm Of Oth$70,751$28,765$78,515$49,360$101,035$27,636$178,0312,913.7%CANCER$178,7209,577.9%$356,751.04-$7,985$16,359$12.28$12.33$24.61
4L03319L03319~L03319M0026GB61240982N55-64Employee/SelfYNIll-Defined ConditionsAbnormalities Of Gait And MobilityUnspecified Nephritic Syndrome$5,411$843$4,558$0$6,500$4,312$10,8130.0%CANCER$333,8969,684.2%$344,708.45$1,270$30,800$0.75$23.03$23.78
5L03319L03319~L03319MR026GB6245670148N55-64Employee/SelfYYDigestive SystemCrohns Disease Regional EnteritisEnc Attention Artificial Openings$146,236$14,063$51,728$129,473$36,246$46,309$212,0280.0%INFLAMMATORY CONDITIONS$79,9089,794.7%$291,935.85$650$1,550$14.63$5.51$20.14
6L03319L03319~L03319M0026GB6254601116N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Bronchus & LungEnc Screening Malignant Neoplasms$265,827$8,400$10,066$0$275,132$9,162$284,2938,398.4%DIABETES$8680.0%$285,161.45$7,971$123$19.61$0.06$19.67
7L03319L03319~L03319M0026GB6213049299N45-54Spouse/PartnerYNHealth StatusEnc Adj & Management Implanted DevcOther Spondylopathies$82,523$36,708$12,647$0$117,976$13,902$131,878123.3%INFLAMMATORY CONDITIONS$126,8587,728.2%$258,735.71$367$14,799$9.10$8.75$17.85
8L03319L03319~L03319M0026GB624958404N35-44Spouse/PartnerYYEndocrine/MetabolicType 2 Diabetes MellitusOsteomyelitis$136,044$24,329$38,596$135,155$10,637$53,178$198,9690.0%DIABETES$14,7450.0%$213,714.31$3,113$1,457$13.73$1.02$14.74
9L03319L03319~L03319M0016GB789152158N65+Spouse/PartnerYYNeoplasms - MalignantMalignant Neoplasm Of TonsilHypotension$156,558$5,646$17,187$0$159,410$19,981$179,3900.0%PARKINSONS DISEASE$2,1040.0%$181,493.94$6,201$41$12.38$0.15$12.52
10L03319L03319~L03319M0016GB7774227794N35-44Employee/SelfYYNeoplasms - MalignantEncounter For Other AftercareMal Neo Bone & Ac Oth & Uns Sites$78,615$64,821$36,784$67,073$98,030$15,118$180,2203,480.3%CONTRACEPTION$7010.0%$180,921.04$11,723$133$12.43$0.05$12.48
11L03319L03319~L03319M0026GB6350504463N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Of BreastPain Not Elsewhere Classified$15,140$1,661$5,713$0$16,956$5,558$22,5140.0%CANCER$148,7429,983.9%$171,256.60$670$15,063$1.55$10.26$11.81
12L03319L03319~L03319M0026GB689224664N45-54Employee/SelfYNDigestive SystemHemorrhoids Perian Venous ThrombAbdominal And Pelvic Pain$5,196$1,894$7,409$0$7,240$7,259$14,4990.0%INFLAMMATORY CONDITIONS$138,1159,958.0%$152,613.94$170$13,072$1.00$9.53$10.53
13L03319L03319~L03319MR016GB789532810N55-64Employee/SelfNNNeoplasms - MalignantMalignant Neoplasm Of BreastEncounter For Other Aftercare$56,858$5,442-$17,254-$22,152$50,992$16,205$45,045463.9%GI DISORDERS$89,5989,546.7%$134,643.39$897$9,919$3.11$6.18$9.29
14L03319L03319~L03319M0016GB791809870N65+Spouse/PartnerYNCirculatory SystemNonrheumatic Aortic Valve DisordersOther Spondylopathies$85,808$24,769$10,222$70,451$38,072$12,276$120,7990.0%ANAPHYLAXIS$1,3940.0%$122,193.28$24,812$342$8.33$0.10$8.43
15L03319L03319~L03319M0026GB689044321N45-54Employee/SelfYNMusculoskeletal SystemCervical Disc DisordersOther Spondylopathies$27,796$4,387$6,211$0$30,440$7,954$38,3940.0%INFLAMMATORY CONDITIONS$75,2339,773.4%$113,627.36$2,142$7,003$2.65$5.19$7.84
16L03319L03319~L03319M0016GB7122913337N35-44Employee/SelfYNCirculatory SystemAtrial Fibrillation And FlutterDizziness And Giddiness$107,616$1,142$566$94,601$4,160$10,563$109,3250.0%IRREGULAR HEART BEAT$1440.0%$109,468.57$150$5$7.54$0.01$7.55
17L03319L03319~L03319M0016GB791701320N55-64Employee/SelfYNMusculoskeletal SystemSpondylosisConjunctivitis$353$115$392$0$0$861$8610.0%INFLAMMATORY CONDITIONS$105,4777,867.3%$106,338.14$0$7,050$0.06$7.28$7.34
18L03319L03319~L03319M0016GB789158029N55-64Spouse/PartnerYNMusculoskeletal SystemOsteoarthritis Of HipCholecystitis$40,462$18,660$20,138$0$67,587$11,674$79,2610.0%DIABETES$14,9520.0%$94,213.16$21,866$1,896$5.47$1.03$6.50
19L03319L03319~L03319M0016GB7774226983N26-34Employee/SelfNNIll-Defined ConditionsPain In Throat And ChestGastro-Esophageal Reflux Disease$9,841$3,294$3,004$0$12,957$3,182$16,1400.0%INFLAMMATORY CONDITIONS$76,4309,918.2%$92,569.36$104$0$1.11$5.27$6.39
20L03319L03319~L03319M0016GB7890126831N00-04Child/Other DependentYNNewbornOth Resp Cond Orig Perintl PeriodBacterial Sepsis Of Newborn$81,525$3,448$4,392$80,783$1,260$7,322$89,3650.0%SKIN INFECTIONS$00.0%$89,364.71$80,783$0$6.16$0.00$6.16
21L03319L03319~L03319M0016GB7122363294N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Of BreastUnspecified Lump In Breast$78,101$3,406$3,715$0$73,155$12,068$85,2230.0%DEPRESSION$9010.0%$86,124.07$2,738$114$5.88$0.06$5.94
22L03319L03319~L03319M0016GB789457336N55-64Employee/SelfYNMusculoskeletal SystemIo Postproc Comp D/O Msk Sys NecOsteoarthritis Of Knee$31,355$28,752$23,956$54,592$18,777$10,694$84,0630.0%INFLAMMATION/PAIN$1,2220.0%$85,284.92$140$156$5.80$0.08$5.88
23L03319L03319~L03319M0026GB689613137N45-54Employee/SelfYYNeoplasms - MalignantMalignant Melanoma Of SkinCalculus Of Kidney And Ureter$60,508$7,292$8,883$0$14,043$62,639$76,6837,009.2%HIGH CHOLESTEROL$4040.0%$77,086.22$7,757$0$5.29$0.03$5.32
24L03319L03319~L03319M0016GB7300548958N35-44Employee/SelfYNNANANA$0$0$0$0$0$0$00.0%INFLAMMATORY CONDITIONS$72,3239,995.3%$72,323.41$0$0$0.00$4.99$4.99
25L03319L03319~L03319M0016GB738714502N55-64Employee/SelfYNHealth StatusEnc Gen Exam No Complaint Suspct DxEnc Screening Malignant Neoplasms$334$243$316$0$0$893$8930.0%INFLAMMATORY CONDITIONS$70,8059,991.8%$71,698.26$87$6,622$0.06$4.88$4.95
26L03319L03319~L03319M0016GB789514155N45-54Employee/SelfYNDigestive SystemUlcerative ColitisPeritonsillar Abscess$19,186$5,985$2,027$12,410$12,162$2,626$27,198651.0%INFLAMMATORY CONDITIONS$43,8119,281.1%$71,008.88$261$6,300$1.88$3.02$4.90
27L03319L03319~L03319M0016GB718545666N55-64Spouse/PartnerNNInjury & PoisoningIntracranial InjuryPyothorax$67,058$2,924$19$0$0$70,000$70,0000.0%NA$00.0%$70,000.23$0$0$4.83$0.00$4.83
28L03319L03319~L03319M0016GB789673202N55-64Spouse/PartnerYNHealth StatusEnc Screening Malignant NeoplasmsSuperficial Injury Of Thorax$4,558$265$63$0$3,738$1,147$4,8850.0%INFLAMMATORY CONDITIONS$63,51810,000.0%$68,403.14$0$0$0.34$4.38$4.72
29L03319L03319~L03319M0026GB689412918N45-54Spouse/PartnerYNHealth StatusEnc Screening Malignant NeoplasmsGastritis And Duodenitis$621$450$230$0$0$1,301$1,3010.0%INFLAMMATORY CONDITIONS$65,8789,997.8%$67,178.57$0$0$0.09$4.54$4.63
30L03319L03319~L03319M0016GB789176500N45-54Employee/SelfYNBehavioral HealthReaction Severe Stress & Adjust D/OPsoriasis$318$308$373$0$0$999$9990.0%INFLAMMATORY CONDITIONS$64,5289,934.9%$65,527.68$0$6,367$0.07$4.45$4.52
31L03319L03319~L03319M0026GB6226610609N55-64Employee/SelfYNMusculoskeletal SystemOther & Unspecified OsteoarthritisAbnormal Findings Dx Imaging Lung$50,893$5,924$6,808$0$57,062$6,562$63,6240.0%DEPRESSION$9430.0%$64,567.44$348$85$4.39$0.07$4.45
32L03319L03319~L03319M0016GB789557540N12-17Child/Other DependentYNNervous SystemOther Disorders Of BrainOth Congenital Malform Nerv Sys$57,639$4,866$1,959$56,335$1,537$6,591$64,4630.0%INFECTIONS$30.0%$64,466.32$1,222$0$4.45$0.00$4.45
33L03319L03319~L03319M0016GB7203183493N35-44Spouse/PartnerYNBehavioral HealthAlcohol Related DisordersInguinal Hernia$27,245$19,563$17,470$22,985$36,766$4,528$64,2780.0%DEPRESSION$1410.0%$64,418.93$13,395$24$4.43$0.01$4.44
34L03319L03319~L03319M0026GB689658344N35-44Employee/SelfYNGenitourinary SystemObstructive And Reflux UropathyEnc For Contraceptive Management$41,880$17,586$581$0$52,783$7,264$60,0470.0%INFECTIONS$00.0%$60,047.20$188$0$4.14$0.00$4.14
35L03319L03319~L03319M0026GB692205129N55-64Spouse/PartnerYNMusculoskeletal SystemSpondylosisMononeuropathies Of Upper Limb$47,983$5,922$4,994$0$48,879$10,020$58,8990.0%INFLAMMATION/PAIN$2940.0%$59,193.79$5,885$75$4.06$0.02$4.08
36L03319L03319~L03319M0026GB689027344N45-54Employee/SelfYNMusculoskeletal SystemCervical Disc DisordersInjury Musc Fasc Tendon Forarm Levl$27,251$15,148$9,008$0$41,080$10,327$51,4070.0%HORMONE SUPPLEMENTATION$1,2270.0%$52,634.08$16,214$84$3.55$0.08$3.63
37L03319L03319~L03319M0016GB7249275402N05-11Child/Other DependentYNHealth StatusEnc Gen Exam No Complaint Suspct DxHypofunction D/O Pituitary Gland$1,182$360$74$0$0$1,616$1,6160.0%GROWTH DEFICIENCY$49,84810,000.0%$51,464.37$0$3,648$0.11$3.44$3.55
Total$2,906,509$374,213$373,093$1,531,999$1,634,125$487,691$3,653,8161,725.5%$2,126,4159,387.2%$5,780,231$204,776$168,040$252.06$146.69$398.75

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and Community Care Health Plan of Georgia, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In 17 southeastern counties of New York: Anthem HealthChoice Assurance, Inc., and Anthem HealthChoice HMO, Inc. In these same counties Anthem Blue Cross and Blue Shield HP is the trade name of Anthem HP, LLC. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc. trades as Anthem HealthKeepers providing HMO coverage, and their service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out-of-network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

This confidential information should not be distributed without prior written consent and should only be used to review health care utilization.

Pharmacy claims runout/paid through date is always set to the Latest Data Loaded month, for every time period. Medical claims runout/paid through date is indicated in the report header.
Latest Data Loaded: 02/2026 Run Date: 03/18/2026

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File details come from the government source that posted it. Updated .