COE_HCC_NO_PHI_25000_2023-2024.pdf
PDF 130 KB Posted
- Attached to
- Pharmacy Benefits 2025-2026
- Solicitation number
- 2025-011
- Issued by
- Hidalgo County, Texas
About this file
The document is a high-cost claim (HCC) report for the City of Edinburg, Texas, covering medical and pharmacy benefits for the period of October 2023 to September 2024. The report details 52 individual claims with a total medical and pharmacy paid amount of $3,739,247.53, using a high-cost threshold of $25,000. The claims encompass various benefit packages including PPO Active, PPO Retiree Pre-65, and HMO Active, and cover subscribers, spouses, and dependent children across different age and gender bands.
The claims data reveals a diverse range of primary diagnoses, including chronic conditions like ischemic heart disease, malignant neoplasms, and diabetes, as well as some COVID-19 confirmed cases. The pharmacy paid amounts vary significantly, with some claims having minimal pharmacy costs and others exceeding $200,000. The report provides detailed metrics on medical and pharmacy expenses, member relationships, age and gender bands, enrollment status, and benefit packages, offering a comprehensive overview of healthcare utilization for the City of Edinburg's insurance plan.
View the file
Other files
Show all 21
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
COE HCC NO PHI 25000_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
Subscriber Male 50-59 No PPO ACTIVE 373,445.87
Subscriber Female 50-59 Yes PPO RETIREE PRE 65 117,105.88
Subscriber Female 50-59 Yes PPO RETIREE PRE 65 6,526.22
Subscriber Male 20-29 Yes PPO ACTIVE 212,391.32
Subscriber Male 40-49 Yes PPO ACTIVE 193,611.94
Spouse Female 40-49 Yes PPO ACTIVE 154,406.37
Subscriber Male 65+ Yes PPO ACTIVE 142,039.95
Subscriber Male 50-59 No HMO ACTIVE 103,922.15
Spouse Male 50-59 Yes PPO ACTIVE 115,547.06
Subscriber Male 40-49 Yes PPO ACTIVE 101,445.69
Subscriber Male 65+ No PPO RETIREE PRE 65 77,377.29
Subscriber Male 60-64 Yes PPO ACTIVE 73,588.77
Dependent Child Male <1-19 Yes PPO ACTIVE 74,126.33
Subscriber Female 40-49 Yes PPO ACTIVE 1,546.99
Subscriber Male 60-64 Yes HMO RETIREE PRE 65 71,907.78
Dependent Child Male <1-19 Yes PPO ACTIVE 753.06
Subscriber Female 50-59 Yes HMO ACTIVE 51,085.98
Dependent Child Male <1-19 Yes PPO ACTIVE 53,221.83
Subscriber Female 60-64 Yes PPO ACTIVE 44,281.69
Subscriber Male 40-49 Yes PPO ACTIVE 52,087.12
Subscriber Female 50-59 Yes PPO ACTIVE 47,246.57
Subscriber Male 30-39 No HMO ACTIVE 43,572.12
Subscriber Male 30-39 Yes PPO ACTIVE 52,504.44
Subscriber Male 65+ Yes PPO ACTIVE 48,401.61
Dependent Child Male <1-19 Yes PPO ACTIVE 45,289.12
Subscriber Female 40-49 Yes HMO ACTIVE 47,981.95
Subscriber Male 40-49 Yes PPO ACTIVE 44,638.43
Subscriber Male 65+ No PPO ACTIVE 43,817.23
Subscriber Male 40-49 Yes PPO ACTIVE 1,762.08
Dependent Child Male <1-19 Yes PPO ACTIVE 42,404.99
Subscriber Female 40-49 Yes PPO ACTIVE 41,624.22
Spouse Female 50-59 Yes PPO ACTIVE 2,006.08
(Paid)
(CITY OF EDINBURG 000243483: ALL)
($25,000)
(Oct 2023 - Sep 2024)
(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)
Member Relationship Description Member Age/Gender Band Currently Enrolled Indicator Benefit Package Medical Paid
Subscriber Male 60-64 Yes PPO RETIREE PRE 65 38,240.98
Subscriber Male 40-49 Yes PPO ACTIVE 36,109.30
Subscriber Female 40-49 Yes PPO ACTIVE 36,805.13
Subscriber Female 50-59 Yes PPO ACTIVE 32,878.08
Subscriber Male 40-49 Yes PPO ACTIVE 8,035.69
Dependent Child Male <1-19 Yes PPO ACTIVE 34,888.20
Dependent Child Female <1-19 Yes PPO ACTIVE 7,261.89
Subscriber Female 40-49 Yes PPO ACTIVE 31,550.78
Subscriber Female 30-39 No PPO ACTIVE 29,826.62
Subscriber Female 30-39 Yes PPO ACTIVE 14,167.59
Subscriber Male 40-49 Yes PPO ACTIVE 24,062.23
Subscriber Female 40-49 Yes PPO ACTIVE 28,300.32
Spouse Male 60-64 Yes PPO ACTIVE 27,691.44
Subscriber Male 50-59 Yes PPO ACTIVE 5,113.54
Subscriber Male 50-59 Yes HMO ACTIVE 22,842.90
Spouse Female 40-49 Yes PPO ACTIVE 18,562.40
Spouse Female 50-59 Yes HMO ACTIVE 19,172.85
Subscriber Male 20-29 Yes PPO ACTIVE 25,716.91
Spouse Female 50-59 Yes PPO ACTIVE 9,397.84
Subscriber Male 20-29 No HMO ACTIVE 25,067.58
Query Totals: 52 2,957,360.40
Report Totals: 52 2,957,360.40
Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
3,239.28 376,685.15 A41 - Other septicaemia No
96,924.41 214,030.29 I25 - Chronic ischaemic heart disease No
207,296.86 213,823.08 Z94 - Transplanted organ and tissue status No
34.44 212,425.76 Z51 - Other medical care Yes
14,855.66 208,467.60 Z51 - Other medical care No
215.58 154,621.95 C50 - Malignant neoplasm of breast No
9,801.94 151,841.89 I25 - Chronic ischaemic heart disease No
22,707.42 126,629.57 C25 - Malignant neoplasm of pancreas No
100.43 115,647.49 K57 - Diverticular disease of intestine No
1,192.41 102,638.10 R91 - Abnormal findings on diagnostic imaging of lung Yes
847.55 78,224.84 I13 - Hypertensive heart and renal disease No
4,409.11 77,997.88 I25 - Chronic ischaemic heart disease Yes
128.60 74,254.93 F84 - Pervasive developmental disorders No
71,637.73 73,184.72 Z12 - Special screening examination for neoplasms Yes
458.78 72,366.56 G61 - Inflammatory polyneuropathy Yes
63,258.07 64,011.13 Z23 - Need for immunization against single bacterial diseases No
11,936.36 63,022.34 A41 - Other septicaemia Yes
8,815.27 62,037.10 Z48 - Other surgical follow-up care No
15,342.79 59,624.48 Z51 - Other medical care Yes
5,433.49 57,520.61 I21 - Acute myocardial infarction No
7,413.43 54,660.00 G81 - Hemiplegia Yes
10,457.80 54,029.92 I63 - Cerebral infarction Yes
22.65 52,527.09 C64 - Malignant neoplasm of kidney, except renal pelvis No
3,820.35 52,221.96 I25 - Chronic ischaemic heart disease Yes
4,867.08 50,156.20 J32 - Chronic sinusitis Yes
200.57 48,182.52 Q21 - Congenital malformations of cardiac septa Yes
211.48 44,849.91 G35 - Multiple sclerosis No
0.00 43,817.23 I70 - Atherosclerosis No
41,739.92 43,502.00 L40 - Psoriasis No
229.85 42,634.84 J03 - Acute tonsillitis Yes
3.94 41,628.16 N70 - Salpingitis and oophoritis No
36,823.97 38,830.05 Z12 - Special screening examination for neoplasms Yes
(Paid)
(CITY OF EDINBURG 000243483: ALL)
($25,000)
(Oct 2023 - Sep 2024)
(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)
Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
327.61 38,568.59 N30 - Cystitis Yes
858.95 36,968.25 I21 - Acute myocardial infarction No
157.03 36,962.16 N93 - Other abnormal uterine and vaginal bleeding No
3,579.22 36,457.30 A41 - Other septicaemia No
27,936.89 35,972.58 R06 - Abnormalities of breathing No
28.33 34,916.53 K35 - Acute appendicitis No
26,129.14 33,391.03 L94 - Other localized connective tissue disorders No
397.37 31,948.15 J34 - Other disorders of nose and nasal sinuses No
793.03 30,619.65 K80 - Cholelithiasis Yes
15,455.68 29,623.27 E04 - Other nontoxic goitre No
5,106.17 29,168.40 S46 - Injury of muscle and tendon at shoulder and upper arm level No
0.00 28,300.32 I47 - Paroxysmal tachycardia No
40.34 27,731.78 M50 - Cervical disc disorders No
22,299.68 27,413.22 E11 - Non-insulin-dependent diabetes mellitus Yes
4,166.02 27,008.92 I70 - Atherosclerosis Yes
7,644.94 26,207.34 D25 - Leiomyoma of uterus Yes
6,599.00 25,771.85 D25 - Leiomyoma of uterus No
45.26 25,762.17 K35 - Acute appendicitis No
15,895.25 25,293.09 E11 - Non-insulin-dependent diabetes mellitus No
0.00 25,067.58 K56 - Paralytic ileus and intestinal obstruction without hernia No
781,887.13 3,739,247.53
781,887.13 3,739,247.53
File details come from the government source that posted it. Updated .