Attachment 2C. HCCs Oct 2025 - Feb 2026-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_29 PM.xlsx

XLSX spreadsheet 627 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 for the Gloucester County School Board's health insurance plan, covering the period of October 2025 through February 2026. The report identifies 13 high-cost claimants with individual claim amounts exceeding $50,000, representing the top utilizers of medical and pharmacy benefits within the school board's total account. The data encompasses medical claims, pharmacy claims, inpatient services, outpatient services, and professional services, with claims evaluated on both paid and incurred bases. The report was generated on March 18, 2026, with the latest data loaded through February 2026, and includes analysis of benefit packages designated as 6GB6 and 6GB7.

The aggregate claims for the 13 identified high-cost claimants total $1,215,064, with medical claims accounting for $651,317 (53.6% of total) and pharmacy claims totaling $563,748 (46.4% of total). The top claimant incurred $223,324 in total costs, driven primarily by a malignant neoplasm diagnosis with high specialty drug spend at 9,001.6 percent of pharmacy costs. Primary health conditions among the cohort include malignant neoplasms, circulatory system disorders, musculoskeletal conditions, and behavioral health issues, with specialty pharmacy costs representing a significant portion of total expenditures across multiple claimants. The per-member-per-month (PMPM) cost for the identified high-cost population averages $207.88, with medical PMPM at $111.43 and pharmacy PMPM at $96.45. The report demonstrates that member engagement and active status vary within this population, with 12 of 13 claimants showing active membership status during the analysis period.

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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 2A. HCCs Sept 2023 - Oct 2024-GLOUCESTER COUNTY SCHOOL BOARD(Total Account)_HCC-01_20260318 03_32 PM.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 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 2025 - Feb 2026 • 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~L03319M0026GB689152158N65+Spouse/PartnerYNNeoplasms - MalignantMalignant Neoplasm Of OropharynxOth Sx Signs Invlv Digestv Sys Abd$208,426$3,531$4,197$0$212,514$3,640$216,1559,001.6%INFECTIONS$7,1690.0%$223,323.99$24,568$419$36.98$1.23$38.21
2L03319L03319~L03319M0026GB61240982N55-64Employee/SelfYYMusculoskeletal SystemOther Deforming DorsopathiesOther & Uns Polyneuropathies$1,591$273$1,376$0$1,591$1,649$3,2400.0%CANCER$126,9139,791.4%$130,152.90$231$75,892$0.55$21.71$22.27
3L03319L03319~L03319M0016GB791066779N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Of Corpus UteriOth Trnsitry Nn Electrol Metab Dist$2,992$9$0$0$2,693$307$3,0000.0%CANCER$119,5429,997.1%$122,541.82$29$28,505$0.51$20.45$20.97
4L03319L03319~L03319MR016GB784189513N55-64Employee/SelfYNNeoplasms - MalignantMalignant Neoplasm Of BreastAbnormal Findings Dx Imaging Lung$25,200$1,446$3,212$0$27,201$2,656$29,8577,533.0%CANCER$83,0539,548.2%$112,910.40$919$19,595$5.11$14.21$19.32
5L03319L03319~L03319M0016GB791580387N55-64Spouse/PartnerYNNeoplasms - MalignantMalignant Neoplasm Of RectumEncounter For Other Aftercare$64,945$18,110$4,800$0$76,871$10,983$87,8551,269.1%CANCER$7469,339.5%$88,600.22$11,268$0$15.03$0.13$15.16
6L03319L03319~L03319M0016GB715233804N45-54Employee/SelfYNInjury & PoisoningComp Oth Intrl Prosth Devc Impl GftCerebral Palsy$44,326$1,070$2,561$0$45,289$2,668$47,9570.0%INFLAMMATORY CONDITIONS$39,5679,992.2%$87,523.93$44,803$7$8.20$6.77$14.97
7L03319L03319~L03319M0016GB789638175N55-64Employee/SelfYNCirculatory SystemAtrial Fibrillation And FlutterOth Interstitial Pulmonary Diseases$76,984$694$1,257$0$75,297$3,638$78,9350.0%ANTICOAGULATION$2,7050.0%$81,640.18$619$730$13.50$0.46$13.97
8L03319L03319~L03319M0026GB6758431830N45-54Spouse/PartnerYYCirculatory SystemAcute Myocardial InfarctionParoxysmal Tachycardia$52,030$12,583$8,251$42,591$12,597$17,677$72,8650.0%DIABETES$6,3840.0%$79,248.64$6,022$44$12.47$1.09$13.56
9L03319L03319~L03319M0026GB691009693N26-34Employee/SelfYNBehavioral HealthPersistent Mood Affect DisordersSleep Disorders$490$94$92$0$0$676$6760.0%SLEEP DISORDERS$68,8809,526.1%$69,555.78$13$0$0.12$11.78$11.90
10L03319L03319~L03319M0026GB6213049299N45-54Spouse/PartnerYNIll-Defined ConditionsAbnormalities Of Heart BeatOther Anxiety Disorders$1,369$478$1,944$0$1,480$2,311$3,7910.0%INFLAMMATORY CONDITIONS$56,6137,394.5%$60,404.23$2,317$19,505$0.65$9.69$10.33
11L03319L03319~L03319MS026GB6774227794N35-44Employee/SelfNNNeoplasms - MalignantMal Neo Bone & Ac Oth & Uns SitesHemorrhage Not Elsewhere Classified$39,982$4,917$9,007$0$11,655$42,251$53,9061,743.5%INFECTIONS$4750.0%$54,380.65$6$0$9.22$0.08$9.30
12L03319L03319~L03319M0026GB6228177713N55-64Spouse/PartnerYYMusculoskeletal SystemOsteoarthritis Of KneeAbnormal Results Function Studies$45,687$4,411$1,883$0$48,531$3,449$51,9800.0%GOUT$4230.0%$52,403.20$339$409$8.89$0.07$8.97
13L03319L03319~L03319MR016GB791701320N55-64Employee/SelfYNNervous SystemMigrainePain Not Elsewhere Classified$968$88$44$0$0$1,100$1,1006,820.9%INFLAMMATORY CONDITIONS$51,2788,591.8%$52,378.32$0$10,406$0.19$8.77$8.96
Total$564,989$47,704$38,623$42,591$515,721$93,005$651,3173,659.7%$563,7489,132.5%$1,215,064$91,133$155,512$111.43$96.45$207.88

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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