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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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
| Segmentation | Member Details | Claim Details | |||
| Rank | Group ID | Subgroup | Benefit |
Package ID Scrambled Claimant ID Prior Period
| HCC | Age | |
| Bands | Relationship | Active |
| (Yes/No) | Member Engaged | Primary |
Health Condition Category Primary Medical Diagnosis Contributing to High Cost Secondary Medical Diagnosis Contributing
| to High Cost | Primary Medical Diagnosis Claim |
| Amount | Secondary |
Medical Diagnosis Claim
| Amount | All Other Medical Diagnosis Claim |
| Amount | Inpatient |
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
| Amount | Most | ||
| Recent Month Pharmacy Claim Amount | Medical Claim Amount PMPM | Pharmacy Claim Amount PMPM | Total Claim Amount PMPM |
| 1 | L03319 | L03319~L03319M002 | 6GB6 | 89152158 | N | 65+ | Spouse/Partner | Y | N | Neoplasms - Malignant | Malignant Neoplasm Of Oropharynx | Oth Sx Signs Invlv Digestv Sys Abd | $208,426 | $3,531 | $4,197 | $0 | $212,514 | $3,640 | $216,155 | 9,001.6% | INFECTIONS | $7,169 | 0.0% | $223,323.99 | $24,568 | $419 | $36.98 | $1.23 | $38.21 |
| 2 | L03319 | L03319~L03319M002 | 6GB6 | 1240982 | N | 55-64 | Employee/Self | Y | Y | Musculoskeletal System | Other Deforming Dorsopathies | Other & Uns Polyneuropathies | $1,591 | $273 | $1,376 | $0 | $1,591 | $1,649 | $3,240 | 0.0% | CANCER | $126,913 | 9,791.4% | $130,152.90 | $231 | $75,892 | $0.55 | $21.71 | $22.27 |
| 3 | L03319 | L03319~L03319M001 | 6GB7 | 91066779 | N | 55-64 | Employee/Self | Y | N | Neoplasms - Malignant | Malignant Neoplasm Of Corpus Uteri | Oth Trnsitry Nn Electrol Metab Dist | $2,992 | $9 | $0 | $0 | $2,693 | $307 | $3,000 | 0.0% | CANCER | $119,542 | 9,997.1% | $122,541.82 | $29 | $28,505 | $0.51 | $20.45 | $20.97 |
| 4 | L03319 | L03319~L03319MR01 | 6GB7 | 84189513 | N | 55-64 | Employee/Self | Y | N | Neoplasms - Malignant | Malignant Neoplasm Of Breast | Abnormal Findings Dx Imaging Lung | $25,200 | $1,446 | $3,212 | $0 | $27,201 | $2,656 | $29,857 | 7,533.0% | CANCER | $83,053 | 9,548.2% | $112,910.40 | $919 | $19,595 | $5.11 | $14.21 | $19.32 |
| 5 | L03319 | L03319~L03319M001 | 6GB7 | 91580387 | N | 55-64 | Spouse/Partner | Y | N | Neoplasms - Malignant | Malignant Neoplasm Of Rectum | Encounter For Other Aftercare | $64,945 | $18,110 | $4,800 | $0 | $76,871 | $10,983 | $87,855 | 1,269.1% | CANCER | $746 | 9,339.5% | $88,600.22 | $11,268 | $0 | $15.03 | $0.13 | $15.16 |
| 6 | L03319 | L03319~L03319M001 | 6GB7 | 15233804 | N | 45-54 | Employee/Self | Y | N | Injury & Poisoning | Comp Oth Intrl Prosth Devc Impl Gft | Cerebral Palsy | $44,326 | $1,070 | $2,561 | $0 | $45,289 | $2,668 | $47,957 | 0.0% | INFLAMMATORY CONDITIONS | $39,567 | 9,992.2% | $87,523.93 | $44,803 | $7 | $8.20 | $6.77 | $14.97 |
| 7 | L03319 | L03319~L03319M001 | 6GB7 | 89638175 | N | 55-64 | Employee/Self | Y | N | Circulatory System | Atrial Fibrillation And Flutter | Oth Interstitial Pulmonary Diseases | $76,984 | $694 | $1,257 | $0 | $75,297 | $3,638 | $78,935 | 0.0% | ANTICOAGULATION | $2,705 | 0.0% | $81,640.18 | $619 | $730 | $13.50 | $0.46 | $13.97 |
| 8 | L03319 | L03319~L03319M002 | 6GB6 | 758431830 | N | 45-54 | Spouse/Partner | Y | Y | Circulatory System | Acute Myocardial Infarction | Paroxysmal Tachycardia | $52,030 | $12,583 | $8,251 | $42,591 | $12,597 | $17,677 | $72,865 | 0.0% | DIABETES | $6,384 | 0.0% | $79,248.64 | $6,022 | $44 | $12.47 | $1.09 | $13.56 |
| 9 | L03319 | L03319~L03319M002 | 6GB6 | 91009693 | N | 26-34 | Employee/Self | Y | N | Behavioral Health | Persistent Mood Affect Disorders | Sleep Disorders | $490 | $94 | $92 | $0 | $0 | $676 | $676 | 0.0% | SLEEP DISORDERS | $68,880 | 9,526.1% | $69,555.78 | $13 | $0 | $0.12 | $11.78 | $11.90 |
| 10 | L03319 | L03319~L03319M002 | 6GB6 | 213049299 | N | 45-54 | Spouse/Partner | Y | N | Ill-Defined Conditions | Abnormalities Of Heart Beat | Other Anxiety Disorders | $1,369 | $478 | $1,944 | $0 | $1,480 | $2,311 | $3,791 | 0.0% | INFLAMMATORY CONDITIONS | $56,613 | 7,394.5% | $60,404.23 | $2,317 | $19,505 | $0.65 | $9.69 | $10.33 |
| 11 | L03319 | L03319~L03319MS02 | 6GB6 | 774227794 | N | 35-44 | Employee/Self | N | N | Neoplasms - Malignant | Mal Neo Bone & Ac Oth & Uns Sites | Hemorrhage Not Elsewhere Classified | $39,982 | $4,917 | $9,007 | $0 | $11,655 | $42,251 | $53,906 | 1,743.5% | INFECTIONS | $475 | 0.0% | $54,380.65 | $6 | $0 | $9.22 | $0.08 | $9.30 |
| 12 | L03319 | L03319~L03319M002 | 6GB6 | 228177713 | N | 55-64 | Spouse/Partner | Y | Y | Musculoskeletal System | Osteoarthritis Of Knee | Abnormal Results Function Studies | $45,687 | $4,411 | $1,883 | $0 | $48,531 | $3,449 | $51,980 | 0.0% | GOUT | $423 | 0.0% | $52,403.20 | $339 | $409 | $8.89 | $0.07 | $8.97 |
| 13 | L03319 | L03319~L03319MR01 | 6GB7 | 91701320 | N | 55-64 | Employee/Self | Y | N | Nervous System | Migraine | Pain Not Elsewhere Classified | $968 | $88 | $44 | $0 | $0 | $1,100 | $1,100 | 6,820.9% | INFLAMMATORY CONDITIONS | $51,278 | 8,591.8% | $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 | $651,317 | 3,659.7% | $563,748 | 9,132.5% | $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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