COE_HCC_NO_PHI_25000_2022-2023.pdf

COE HCC_NO PHI_25000

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

Subscriber Male 50-59 No PPO ACTIVE 181,540.24

Subscriber Male 20-29 Yes PPO ACTIVE 317,848.22

Subscriber Male 50-59 No HMO ACTIVE 250,717.15

Subscriber Male 50-59 No HMO ACTIVE 215,825.64

Subscriber Female 50-59 Yes PPO RETIREE PRE 65 9,326.16

Subscriber Female 30-39 No PPO ACTIVE 164,924.88

Dependent Child Male <1-19 No PPO ACTIVE 144,804.17

Subscriber Male 65+ Yes PPO ACTIVE 121,696.27

Dependent Child Male <1-19 No PPO ACTIVE 112,916.61

Dependent Child Female <1-19 No HMO ACTIVE 108,718.57

Subscriber Male 40-49 Yes PPO ACTIVE 101,729.67

Subscriber Male 40-49 No HMO ACTIVE 0.00

Dependent Child Male <1-19 Yes PPO ACTIVE 80,945.93

Subscriber Female 50-59 Yes PPO RETIREE PRE 65 3,344.52

Subscriber Male 50-59 No PPO ACTIVE 78,047.06

Subscriber Male 40-49 Yes PPO ACTIVE 66,052.08

Subscriber Female 40-49 Yes PPO ACTIVE 56,230.25

Subscriber Male 60-64 No PPO RETIREE PRE 65 60,038.03

Subscriber Male 60-64 No HMO ACTIVE 58,973.06

Subscriber Male 20-29 No HMO ACTIVE 1,810.59

Dependent Child Male <1-19 Yes PPO ACTIVE 34,183.84

Subscriber Male 60-64 Yes PPO RETIREE PRE 65 46,519.94

Spouse Female 40-49 Yes PPO ACTIVE 43,691.13

Subscriber Male 40-49 Yes PPO ACTIVE 8,330.82

Dependent Child Male <1-19 Yes PPO ACTIVE 37,559.56

Subscriber Female 30-39 Yes PPO ACTIVE 7,855.66

Subscriber Female 30-39 Yes PPO ACTIVE 22,097.31

Subscriber Male 40-49 Yes PPO ACTIVE 25,274.90

Subscriber Male 65+ Yes PPO ACTIVE 31,905.89

Subscriber Female 50-59 Yes PPO RETIREE PRE 65 681.18

(Paid)

(CITY OF EDINBURG 000243483: ALL)

($25,000)

(Oct 2022 - Sep 2023)

(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)

Member Relationship Description Member Age/Gender Band Currently Enrolled Indicator Benefit Package Medical Paid

Subscriber Male 40-49 Yes PPO ACTIVE 22,159.89

Spouse Female 30-39 No PPO ACTIVE 31,834.74

Subscriber Male 40-49 Yes PPO ACTIVE 6,395.95

Dependent Child Female <1-19 Yes PPO ACTIVE 31,177.84

Subscriber Male 50-59 No PPO ACTIVE 5,984.86

Subscriber Female 50-59 Yes HMO ACTIVE 21,163.57

Subscriber Male 40-49 Yes PPO ACTIVE 28,965.09

Subscriber Male 50-59 Yes PPO RETIREE PRE 65 1,172.15

Spouse Female 50-59 Yes PPO ACTIVE 2,676.16

Dependent Child Female <1-19 Yes PPO ACTIVE 6,597.50

Subscriber Female 40-49 Yes PPO ACTIVE 1,531.43

Subscriber Female 20-29 Yes PPO ACTIVE 21,625.60

Query Totals: 42 2,574,874.11

Report Totals: 42 2,574,874.11

Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed

161,183.41 342,723.65 D64 - Other anaemias No

110.13 317,958.35 Z51 - Other medical care No

1,040.11 251,757.26 G00 - Bacterial meningitis, not elsewhere classified No

19,391.51 235,217.15 C25 - Malignant neoplasm of pancreas No

168,714.10 178,040.26 C90 - Multiple myeloma and malignant plasma cell neoplasms No

0.00 164,924.88 C78 - Secondary malignant neoplasm of respiratory and digestive organs No

0.00 144,804.17 Z38 - Liveborn infants according to place of birth No

12,697.23 134,393.50 M86 - Osteomyelitis No

0.00 112,916.61 Q23 - Congenital malformations of aortic and mitral valves No

0.00 108,718.57 Z38 - Liveborn infants according to place of birth No

538.69 102,268.36 C18 - Malignant neoplasm of colon No

87,896.39 87,896.39 No

235.93 81,181.86 F84 - Pervasive developmental disorders No

74,905.58 78,250.10 R06 - Abnormalities of breathing No

66.90 78,113.96 I48 - Atrial fibrillation and flutter Yes

3,526.63 69,578.71 I48 - Atrial fibrillation and flutter Yes

6,373.35 62,603.60 T50 - Poisoning by diuretics and other and unspecified drugs, medicaments and biological substances

No

2,144.38 62,182.41 I45 - Other conduction disorders Yes

1,059.19 60,032.25 K81 - Cholecystitis No

50,937.37 52,747.96 J11 - Influenza, virus not identified No

13,269.41 47,453.25 Z79 - Long term (current) drug therapy No

550.51 47,070.45 A41 - Other septicaemia No

33.84 43,724.97 C50 - Malignant neoplasm of breast No

30,537.85 38,868.67 R06 - Abnormalities of breathing No

502.51 38,062.07 Z38 - Liveborn infants according to place of birth No

27,027.07 34,882.73 K76 - Other diseases of liver No

10,911.72 33,009.03 C64 - Malignant neoplasm of kidney, except renal pelvis No

7,538.25 32,813.15 S43 - Dislocation, sprain and strain of joints and ligaments of shoulder girdle

No

553.05 32,458.94 N40 - Hyperplasia of prostate No

31,463.95 32,145.13 M06 - Other rheumatoid arthritis No

(Paid)

(CITY OF EDINBURG 000243483: ALL)

($25,000)

(Oct 2022 - Sep 2023)

(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)

Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed

9,853.39 32,013.28 I21 - Acute myocardial infarction No

0.00 31,834.74 G35 - Multiple sclerosis No

25,336.16 31,732.11 I10 - Essential (primary) hypertension Yes

0.00 31,177.84 S83 - Dislocation, sprain and strain of joints and ligaments of knee No

23,718.74 29,703.60 K29 - Gastritis and duodenitis No

8,422.72 29,586.29 N39 - Other disorders of urinary system No

168.12 29,133.21 K42 - Umbilical hernia No

25,963.90 27,136.05 E11 - Non-insulin-dependent diabetes mellitus No

24,122.62 26,798.78 F41 - Other anxiety disorders No

19,702.16 26,299.66 L94 - Other localized connective tissue disorders No

24,704.72 26,236.15 E78 - Disorders of lipoprotein metabolism and other lipidaemias Yes

3,634.37 25,259.97 O34 - Maternal care for known or suspected abnormality of pelvic organs Yes

878,835.96 3,453,710.07

878,835.96 3,453,710.07