COE_HCC_NO_PHI_100000_2023-2024.pdf
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- Attached to
- Pharmacy Benefits 2025-2026
- Solicitation number
- 2025-011
- Issued by
- Hidalgo County, Texas
About this file
This document is a High Cost Claims (HCC) report for the City of Edinburg, Texas, covering a healthcare claims analysis for the period of October 2023 to September 2024. The report provides a detailed breakdown of medical and pharmacy paid claims for 10 subscribers and spouses, categorized by age, gender, benefit package, and enrollment status. The data includes medical and pharmacy paid amounts totaling $1,876,810.88, with individual claims ranging from $102,638.10 to $376,685.15.
The report highlights various medical diagnoses across different age groups and benefit packages, including conditions such as chronic ischemic heart disease, malignant neoplasms, and COVID-19 cases. The claims are primarily associated with PPO (Preferred Provider Organization) and HMO (Health Maintenance Organization) benefit packages, with subscribers predominantly in the 40-59 age ranges. The high cost threshold is set at $100,000, and the report includes both active and retiree pre-65 members, providing a comprehensive overview of healthcare utilization and associated costs for the City of Edinburg's health insurance program.
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Text version
COE HCC NO PHI 100000_2023-2024
Run Date: 6/5/2025
Metrics:
Database:
High Cost Threshold:
Paid Month:
Service Category:
Member Relationship Description Member Age/Gender Band Currently Enrolled Indicator Benefit Package Medical Paid Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
Subscriber Male 50-59 No PPO ACTIVE 373,445.87 3,239.28 376,685.15 A41 - Other septicaemia No
Subscriber Female 50-59 Yes PPO RETIREE PRE 65 117,105.88 96,924.41 214,030.29 I25 - Chronic ischaemic heart disease No
Subscriber Female 50-59 Yes PPO RETIREE PRE 65 6,526.22 207,296.86 213,823.08 Z94 - Transplanted organ and tissue status No
Subscriber Male 20-29 Yes PPO ACTIVE 212,391.32 34.44 212,425.76 Z51 - Other medical care Yes
Subscriber Male 40-49 Yes PPO ACTIVE 193,611.94 14,855.66 208,467.60 Z51 - Other medical care No
Spouse Female 40-49 Yes PPO ACTIVE 154,406.37 215.58 154,621.95 C50 - Malignant neoplasm of breast No
Subscriber Male 65+ Yes PPO ACTIVE 142,039.95 9,801.94 151,841.89 I25 - Chronic ischaemic heart disease No
Subscriber Male 50-59 No HMO ACTIVE 103,922.15 22,707.42 126,629.57 C25 - Malignant neoplasm of pancreas No
Spouse Male 50-59 Yes PPO ACTIVE 115,547.06 100.43 115,647.49 K57 - Diverticular disease of intestine No
Subscriber Male 40-49 Yes PPO ACTIVE 101,445.69 1,192.41 102,638.10 R91 - Abnormal findings on diagnostic imaging of lung Yes
Query Totals: 10 1,520,442.45 356,368.43 1,876,810.88
Report Totals: 10 1,520,442.45 356,368.43 1,876,810.88
(Paid)
(CITY OF EDINBURG 000243483: ALL)
($100,000)
(Oct 2023 - Sep 2024)
(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)
File details come from the government source that posted it. Updated .