Exhibit_35_HMO_Detailed_Utilization_Reports.xlsx

XLSX spreadsheet 82 KB Posted

Attached to
OEIBA Program Commercial HMO, MSP, and MAPD Plans State and local contract opportunity
Solicitation number
EV00000681
Issued by
Oklahoma County, Hobart City, Oklahoma

About this file

Written by GovTribe AI ·

This is an Excel spreadsheet titled "Exhibit 35: Detailed Utilization Reports" for an HMO (Health Maintenance Organization) program, likely associated with the Oklahoma Office of Management and Enterprise Services (OMES), as indicated by the reporting email address. The document provides comprehensive quarterly reporting requirements for healthcare utilization metrics, with reports due 45 days following two months of run-off data (Q1 due July 15, Q2 due October 15, Q3 due January 15, Q4 due April 15). The reporting template includes six distinct tabs covering high-cost claimants, monthly claims, high-level summaries (year-to-date and rolling 12-month periods), and detailed breakdowns of medical and prescription drug expenditures.

The reports capture extensive healthcare utilization data across multiple service categories, including facility inpatient and outpatient services, laboratory tests, mental health and substance abuse treatments, professional services, and prescription drugs. The data reveals a total membership of approximately 1,053,476 members, with total medical and prescription spending increasing from $461,177,809 in the previous period to $492,827,845, representing a 6.8% overall cost increase. Key trends include a 25.4% increase in specialty prescription drug costs, notable increases in facility inpatient surgical costs (15.8%), and significant variations across different healthcare service categories. The reports are designed to provide detailed insights into healthcare spending, utilization patterns, and cost trends for comprehensive program management and analysis.

View the file

Other files for this state and local contract opportunity

Other files attached to OEIBA Program Commercial HMO, MSP, and MAPD Plans, newest first.
File Type Posted
Exhibit_22_Satisfaction_Surveys.xlsx XLSX spreadsheet
Exhibit_28_MAPD_File_and_Changes_Reports.xlsx XLSX spreadsheet
Exhibit_2_Geo-Access_Report.xlsx XLSX spreadsheet
Exhibit_36_MAPD_Detailed_Utilization_Reports.xlsx XLSX spreadsheet
Exhibit_38_Advertising_Approval_Request_Form.docx DOCX document
VendorSecurityAssessment_(1).xlsx XLSX spreadsheet
OMES-FORM-CP-011-Amendment_2.pdf PDF
Attachment_E.docx DOCX document
Exhibit_11_MAPD_Rate_Setting.xlsx XLSX spreadsheet
Exhibit_14_Bid_Submission_Network_Detailed_Reports.xlsx XLSX spreadsheet
Exhibit_16_Large_Claims_Report_for_2023_and_2024.xlsx XLSX spreadsheet
Exhibit_17_Audited_Financial_Statements.xlsx XLSX spreadsheet
Exhibit_1_Standardized_Service_Areas.xlsx XLSX spreadsheet
Exhibit_31_HIPAA,_FWA,_and_Grievance_Reports.xlsx XLSX spreadsheet
Exhibit_32_HMO_Utilization_Reports.xlsx XLSX spreadsheet
Exhibit_37B_Individual_Employer_Experience_Reports.xlsx XLSX spreadsheet
Exhibit_3_Ratio_of_PCPs_to_Members.xlsx XLSX spreadsheet
Exhibit_7_Rate_Development_Supporting__Active_Employees.xlsx XLSX spreadsheet
Fillable_OMESFormCP076.pdf PDF
OMES-FORM-CP-011-Amendment_Q_A.pdf PDF
AttachmentB-NegotiableTerms.docx DOCX document
BID_PACKET_ATTACHMENTS_INSTRUCTIONS.pdf PDF
Exhibit_10_MAPD_Premium_Rate_and_LIS_Quote.docx DOCX document
Exhibit_13_MSP_Premium_Rate.docx DOCX document
Exhibit_20_Member_ID_Card_Example.xlsx XLSX spreadsheet
Exhibit_23_CAHPS_Survery_MAPD.xlsx XLSX spreadsheet
Exhibit_24_OEIBA_Program_Census_Information.xlsx XLSX spreadsheet
Exhibit_27_Minimum_Required_Reporting_List.docx DOCX document
Exhibit_29_Premium_Discrepancy_Reports.xlsx XLSX spreadsheet
Exhibit_33_Network_Changes_Summary.xlsx XLSX spreadsheet
Exhibit_34_Network_Detailed_Reports.xlsx XLSX spreadsheet
Exhibit_8_Rate_Developt_Support_Early_Retirees_Employees.xlsx XLSX spreadsheet
Exhibit_9_MAPD_Benefits_Summary.docx DOCX document
OMESFormCP004.pdf PDF
AttachmentD-ITTerms.pdf PDF
Attachment_A.pdf PDF
Bidder_Instructions.pdf PDF
Exhibit_12_MSP_Benefits_Summary.docx DOCX document
Exhibit_15_New_Supp_Aggregate_Utilization_Exp_.xlsx XLSX spreadsheet
Exhibit_18_License(s).xlsx XLSX spreadsheet
Exhibit_19_Actuary_Certification.xlsx XLSX spreadsheet
Exhibit_21_Organizational_Chart_and_Brand_Logos.xlsx XLSX spreadsheet
Exhibit_25_Carrier_Eligibility_Companion_Guide.pdf PDF
Exhibit_26_OEIBB_Commercial_Carrier_Policy.pdf PDF
Exhibit_30_Member_Services_Reports.xlsx XLSX spreadsheet
Exhibit_37A_Individual_Emp_Experience_Reports_Instructions.docx DOCX document
Exhibit_4_HMO_Plan_Design.docx DOCX document
Exhibit_5_HMO_Premium_Quote.docx DOCX document
Exhibit_6_HMO_Rate_Development.xlsx XLSX spreadsheet
Show all 49

On GovTribe

Work with this file on GovTribe

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

Report Cover

Exhibit 35: Detailed Utilization Reports
[Supplier Name]
OEIBA Program
[Date]
Due45 days following two months of run-off data.
ReportReport TitleTab Name
35aHigh Cost Claimants YTDHigh Cost Claimants YTD
35bMonthly Claims ExhibitMonthly Claims Exhibit
35cHigh Level Summary YTDHigh Level Summary YTD
35dHigh Level Summary (Rolling 12)High Level Sum (Rolling 12)
35eAll Plans YTDAll Plans YTD
35fAll Plans (Rolling 12)All Plans (Rolling 12)
Notes:
1) Submit reports quarterly using this template.
2) Completed template must be submitted electronically as an Excel file.
3) Dates should be updated to reflect current reporting periods. Example: In tab '35b Monthly Claims Exhibit', months incurred reflect 2021 in column A but should be updated accordingly to reflect current information.
4) Send via email by secure domain to: EGIDVendorReporting@omes.ok.gov
5) Report is due 45 days following two months of run-off data. (Q1 due July 15; Q2 due October 15; Q3 due January 15; Q4 due April 15)

35a High Cost Claimants YTD

High Cost Claimants YTD
Plan Year [Year]
Due Date45 days following two months of run-off data.
Instructions on providing the experience segments:

- Provide de-identified large claim data information requested below (dollars and diagnosis)

- Provide information for any claimant over $100,000 in aggregate claims (both medical and pharmacy)

- Data must be provided in the below worksheet - do not refer to a separate document

- Provide information for YTD 2021 on an INCURRED basis

ClaimantPrimary DiagnosisStatusCurrent EligibilityMember TypeMedicalPharmacyTotal
ExampleClaimant 1Some ConditionActiveTermedDependent$82,300$27,500$109,800
1.Claimant 1alcohol dependencyActiveActiveEmployee$ 163,152$ 17,660$ 180,812
2.Claimant 2Atherosclerotic heart disease w unstable anginaActiveActiveSpouse$ 129,628$ 6,462$ 136,090
3.Claimant 3malignant neoplasm of sigmoid colonActiveActiveDependent$ 43,276$ 84,059$ 127,335
4.Claimant 4antineoplastic chemoActiveTermedEmployee$ 56,828$ 60,328$ 117,156
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.

35b Monthly Claims Exhibit

Monthly Claims Exhibit
Plan Year [Year]
Due Date45 days following two months of run-off data.
HMOHMO
Incurred MonthMedicalPharmacyCapitationIncurred MonthMedicalPharmacyCapitation
1/1/21$ 17,000,000$ 3,000,000$ 500,0001/1/20$ 15,000,000$ 3,000,000$ 500,000
2/1/21$ 17,000,000$ 3,000,000$ 500,0002/1/20$ 15,000,000$ 3,000,000$ 500,000
3/1/21$ 17,000,000$ 3,000,000$ 500,0003/1/20$ 15,000,000$ 3,000,000$ 500,000
4/1/21$ 17,000,000$ 3,000,000$ 500,0004/1/20$ 15,000,000$ 3,000,000$ 500,000
5/1/21$ 17,000,000$ 3,000,000$ 500,0005/1/20$ 15,000,000$ 3,000,000$ 500,000
6/1/21$ 17,000,000$ 3,000,000$ 500,0006/1/20$ 15,000,000$ 3,000,000$ 500,000
7/1/21$ 17,000,000$ 3,000,000$ 500,0007/1/20$ 15,000,000$ 3,000,000$ 500,000
8/1/21$ 17,000,000$ 3,000,000$ 500,0008/1/20$ 15,000,000$ 3,000,000$ 500,000
9/1/21$ 17,000,000$ 3,000,000$ 500,0009/1/20$ 15,000,000$ 3,000,000$ 500,000
10/1/2110/1/20$ 15,000,000$ 3,000,000$ 500,000
11/1/2111/1/20$ 15,000,000$ 3,000,000$ 500,000
12/1/2112/1/20$ 15,000,000$ 3,000,000$ 500,000
Total$ 153,000,000$ 27,000,000$ 4,500,000$ 180,000,000$ 36,000,000$ 6,000,000
HMOHMO
Incurred MonthMembersSubscribersDependentsIncurred MonthMembersSubscribersDependents
1/1/212,0001,3007001/1/201,3001,100200
2/1/211,9001,3006002/1/201,3001,000300
3/1/211,9001,3006003/1/201,3001,000300
4/1/211,9001,3006004/1/201,3001,000300
5/1/211,9001,3006005/1/201,3001,000300
6/1/211,9001,3006006/1/201,3001,000300
7/1/211,9001,3006007/1/201,3001,000300
8/1/211,9001,3006008/1/201,3001,000300
9/1/211,9001,3006009/1/201,3001,000300
10/1/2110/1/201,3001,000300
11/1/2111/1/201,3001,000300
12/1/2112/1/201,3001,000300
Notes:
1) This report should be completed for each individual month; however, only submit this report quarterly.
2) Member is the sum of subscribers and dependents.
3) Subscriber is the policy holder.
4) Dependents are all others in the policy. (i.e., spouse, child, etc.)

35c High Level Summary YTD

Monthly Claims Exhibit
Plan Year [Year]
Due Date45 days following two months of run-off data.
January - September
2021 over 2020 Membership Count TrendJan - Sep 2020Jan - Sep 20212021 vs. 2020Jan - Sep 2020Jan - Sep 20212021 vs. 2020Jan - Sep 2020Jan - Sep 20212021 vs. 2020Jan - Sep 2020Jan - Sep 20212021 vs. 2020
EmployeesMembersAverage Age% Female
HMO10,00012,00020.0%20,00024,00020.0%35.0036.002.9%35%36%2.9%
January - September
2021 over 2020 Cost/Utilization TrendPaid Cost TrendUtilization TrendUnit Cost Trend
Facility Inpatient8.5%0.6%7.8%
Facility Outpatient2.3%-3.7%6.1%
Laboratory Outpatient16.4%6.1%9.6%
MHSA9.8%7.2%2.4%
Other Professional Services8.6%6.4%2.1%
Physician Inpatient2.7%1.2%1.4%
Physician Outpatient-0.2%-1.8%1.6%
Radiology Outpatient2.5%-7.5%10.8%
Total Medical4.8%1.9%2.9%
Prescription Drugs Mail Order0.8%0.3%0.5%
Prescription Drugs Retail5.8%2.7%3.0%
Prescription Specialty Drugs25.4%16.2%7.9%
Total Rx12.0%2.8%9.0%
Total (Medical + Rx)6.8%2.1%3.6%

35d High Level Sum (Rolling 12)

High Level Summary (Rolling 12)
Plan Year [Year]
Due Date45 days following two months of run-off data.
Oct - Sept
2021 over 2020 Membership Count TrendOct 2019 - Sept 2020Oct 2020 - Sept 20212021 vs. 2020Oct 2019 - Sept 2020Oct 2020 - Sept 20212021 vs. 2020Oct 2019 - Sept 2020Oct 2020 - Sept 20212021 vs. 2020Oct 2019 - Sept 2020Oct 2020 - Sept 20212021 vs. 2020
EmployeesMembersAverage Age% Female
HMO10,00012,00020.0%20,00024,00020.0%35.0036.002.9%35%36%2.9%
Oct - Sept
2021 over 2021 Cost/Utilization TrendPaid Cost TrendUtilization TrendUnit Cost Trend
Facility Inpatient8.5%0.6%7.8%
Facility Outpatient2.3%-3.7%6.1%
Laboratory Outpatient16.4%6.1%9.6%
MHSA9.8%7.2%2.4%
Other Professional Services8.6%6.4%2.1%
Physician Inpatient2.7%1.2%1.4%
Physician Outpatient-0.2%-1.8%1.6%
Radiology Outpatient2.5%-7.5%10.8%
Total Medical4.8%1.9%2.9%
Prescription Drugs Mail Order0.8%0.3%0.5%
Prescription Drugs Retail5.8%2.7%3.0%
Prescription Specialty Drugs25.4%16.2%7.9%
Total Rx12.0%2.8%9.0%
Total (Medical + Rx)6.8%2.1%3.6%

35e All Plans YTD

All Plans YTD
Plan Year [Year]
Due Date45 days following two months of run-off data.
HMOJan - Sep 2020Jan - Sep 2021
Total Members (Jan - Sep)1,052,8381,053,476
MedicalJan - Sep 2020Jan - Sep 2021Jan - Sep 2020Jan - Sep 20212021/2020Jan - Sep 2020Jan - Sep 2021Jan - Sep 2020Jan - Sep 20212021/20202021/2020
Paid AmountPaid PMPMPaid TrendServiceService/1000 MembersService TrendUnit Cost Trend
Facility Inpatient$71,741,344$77,880,350$68$748.5%211,869213,3442012030.6%7.8%
Facility Inpatient Long Term Care$639,694$524,038$1$0-18.1%3,1312,42132-22.7%5.9%
Facility Inpatient Maternity$8,657,570$8,749,775$8$81.0%45,71643,1624341-5.6%7.0%
Facility Inpatient Medical$24,208,572$24,364,834$23$230.6%87,10888,15183841.1%-0.5%
Facility Inpatient Non Acute$250,223$229,746$0$0-8.2%7331,0651145.2%-36.8%
Facility Inpatient Surgical$37,985,284$44,011,958$36$4215.8%75,18178,54571754.4%10.9%
Facility Outpatient$112,077,447$114,678,642$106$1092.3%518,358499,697492474-3.7%6.1%
Facility Outpatient DME$44,018$47,467$0$07.8%706100-12.9%23.7%
Facility Outpatient Diagnostic Services$6,190,460$6,687,980$6$68.0%10,53111,07410115.1%2.7%
Facility Outpatient Dialysis$2,580,556$2,980,201$2$315.4%5,4026,3535617.5%-1.8%
Facility Outpatient ER$22,005,531$22,378,164$21$211.6%153,869151,088146143-1.9%3.6%
Facility Outpatient Home Health$320,361$341,257$0$06.5%3,7413,28543-12.2%21.3%
Facility Outpatient Other$2,538,270$2,443,957$2$2-3.8%16,39717,43616176.3%-9.5%
Facility Outpatient PT, OT, Speech Therapy$3,374,915$3,644,473$3$37.9%27,24728,01326272.7%5.0%
Facility Outpatient Pharmacy$2,611,813$2,743,727$2$35.0%44,99045,06143430.1%4.9%
Facility Outpatient Specialty Drugs$17,172,999$15,842,706$16$15-7.8%12,95415,132121416.7%-21.0%
Facility Outpatient Supplies and Devices$408,555$454,068$0$011.1%15,48913,2131513-14.7%30.3%
Facility Outpatient Surgery$54,748,534$57,045,381$52$544.1%227,599208,909216198-8.3%13.5%
Facility Outpatient Transportation$81,434$69,260$0$0-15.0%6972004.3%-18.5%
Laboratory Outpatient$11,478,788$13,367,896$11$1316.4%635,722675,2246046416.1%9.6%
Laboratory Outpatient Chemistry Tests$4,355,850$5,760,903$4$532.2%322,414320,776306304-0.6%32.9%
Laboratory Outpatient Other$3,517,695$4,192,719$3$419.1%263,267306,53625029116.4%2.4%
Laboratory Outpatient Pathology$3,605,244$3,414,273$3$3-5.4%50,04147,9124845-4.3%-1.1%
MHSA$9,301,038$10,216,660$9$109.8%99,079106,269941017.2%2.4%
Mental Health Inpatient$2,048,423$2,152,147$2$25.0%6,1146,407664.7%0.3%
Mental Health Office Visits$1,515,818$1,612,451$1$26.3%19,96520,99219205.1%1.2%
Mental Health Other Outpatient$3,950,025$4,602,485$4$416.4%53,73563,748516118.6%-1.8%
Substance Abuse Inpatient$780,330$781,567$1$10.1%2,1562,160220.1%-0.0%
Substance Abuse Office Visits$38,719$35,663$0$0-7.9%52647700-9.4%1.6%
Substance Abuse Other Outpatient$967,723$1,032,346$1$16.6%16,58312,4851612-24.8%41.7%
Other Professional Services$42,056,724$45,697,286$40$438.6%722,710769,2406867306.4%2.1%
Professional Chiropractic Services$2,240,756$2,267,902$2$21.2%73,96074,96770711.3%-0.1%
Professional DME$2,043,006$2,012,996$2$2-1.5%19,63421,33819208.6%-9.3%
Professional Diagnostic Services$3,326,851$3,382,138$3$31.6%54,35256,05052533.1%-1.4%
Professional Dialysis$75,728$86,397$0$014.0%37731900-15.4%34.8%
Professional Home Health$516,858$528,703$0$12.2%6,0046,111661.7%0.5%
Professional Injections$3,140,603$3,176,079$3$31.1%115,382124,9261101198.2%-6.6%
Professional Office Visits$8,627,551$10,501,417$8$1021.6%124,604150,29111814320.5%0.9%
Professional PT, OT, Speech Therapy$4,818,655$4,858,685$5$50.8%190,456188,123181179-1.3%2.1%
Professional Services Other$5,087,740$5,667,151$5$511.3%83,17083,0287979-0.2%11.6%
Professional Specialty Drugs$6,963,689$8,020,896$7$815.1%6,1496,586667.0%7.5%
Professional Supplies and Devices$2,457,710$2,785,060$2$313.3%44,94353,558435119.1%-4.9%
Professional Transportation$2,757,577$2,409,860$3$2-12.7%3,6793,943347.1%-18.5%
Physician Inpatient$10,020,457$10,293,091$10$102.7%41,89342,43240401.2%1.4%
Physician Non-Specialty Inpatient$3,629,661$3,601,679$3$3-0.8%13,85513,7421313-0.9%0.0%
Physician Specialty Inpatient$6,390,796$6,691,411$6$64.6%28,03828,69027272.3%2.3%
Physician Outpatient$47,425,621$47,379,308$45$45-0.2%467,140459,147444436-1.8%1.6%
Physician Non-Specialty ER$131,037$124,918$0$0-4.7%58248810-16.2%13.7%
Physician Non-Specialty Office Visits$19,087,948$18,977,554$18$18-0.6%244,611243,202232231-0.6%-0.0%
Physician Non-Specialty Outpatient Other$1,077,780$1,063,177$1$1-1.4%34,91132,0043330-8.4%7.6%
Physician Non-Specialty Outpatient Surgery$1,636,112$1,655,190$2$21.1%3,9493,66643-7.2%9.0%
Physician Specialty ER$1,905,433$1,903,573$2$2-0.2%8,9318,93388-0.0%-0.1%
Physician Specialty Office Visits$9,224,107$9,346,014$9$91.3%103,602102,5349897-1.1%2.4%
Physician Specialty Outpatient Other$3,369,762$3,398,210$3$30.8%42,49040,5284038-4.7%5.7%
Physician Specialty Outpatient Surgery$10,993,442$10,910,672$10$10-0.8%28,06427,7922726-1.0%0.2%
Radiology Outpatient$29,153,284$29,904,301$28$282.5%180,884167,424172159-7.5%10.8%
Radiology Outpatient CT Scans$4,283,033$4,129,768$4$4-3.6%14,61215,19014143.9%-7.2%
Radiology Outpatient MRIs$4,445,877$4,412,861$4$4-0.8%9,7109,40599-3.2%2.5%
Radiology Outpatient Mammograms$2,907,052$3,230,808$3$311.1%45,08132,0624330-28.9%56.3%
Radiology Outpatient Nuclear Medicine$3,221,936$2,996,850$3$3-7.0%6,1695,70965-7.5%0.5%
Radiology Outpatient Other$937,887$988,613$1$15.3%4,6004,615440.3%5.1%
Radiology Outpatient Therapeutic Radiology$4,385,553$5,379,736$4$522.6%10,0179,301109-7.2%32.1%
Radiology Outpatient Ultrasounds$4,509,739$4,185,021$4$4-7.3%25,95224,7112523-4.8%-2.5%
Radiology Outpatient X-Rays$4,462,208$4,580,643$4$42.6%64,74366,43161632.5%0.0%
Total Medical$333,254,702$349,417,533$317$3324.8%2,877,6552,932,7772,7332,7841.9%2.9%
Prescription DrugsJan - Sep 2020Jan - Sep 2021Jan - Sep 2020Jan - Sep 20212021/2020Jan - Sep 2020Jan - Sep 2021Jan - Sep 2020Jan - Sep 20212021/20202021/2020
Paid AmountPaid PMPMPaid TrendScriptsScripts/1000 MembersScripts TrendUnit Cost Trend
Prescription Drugs Mail Order$3,881,907$3,915,468$3.7$3.70.8%27,27427,37425.926.00.3%0.5%
Generic$1,501,389$1,507,657$1.4$1.40.4%23,72224,01922.522.81.2%-0.8%
Brand Preferred$2,172,475$2,213,676$2.1$2.11.8%2,9382,7192.82.6-7.5%10.1%
Brand None Preferred$102,295$116,684$0.1$0.114.0%1361500.10.110.2%3.4%
OTC$57,782$13,018$0.1$0.0-77.5%198950.20.1-52.0%-53.0%
Missing$47,964$64,433$0.0$0.134.3%2803910.30.439.6%-3.8%
Prescription Drugs Retail$82,362,028$87,193,968$78.2$82.85.8%1,443,4761,483,5361,371.01,408.22.7%3.0%
Generic$32,109,767$35,246,837$30.5$33.59.7%1,285,5311,326,8381,221.01,259.53.2%6.4%
Brand Preferred$43,841,478$44,824,134$41.6$42.52.2%139,110133,831132.1127.0-3.9%6.3%
Brand None Preferred$5,845,828$6,170,639$5.6$5.95.5%12,71311,44312.110.9-10.0%17.3%
OTC$409,678$287,216$0.4$0.3-29.9%4,0295,3893.85.133.7%-47.6%
Missing$155,277$664,218$0.1$0.6327.5%2,0936,0332.05.7188.1%48.4%
Prescription Specialty Drugs$41,679,172$52,300,875$39.6$49.625.4%10,82712,58810.311.916.2%7.9%
Generic$2,072,927$2,707,317$2.0$2.630.5%2,4262,8282.32.716.5%12.0%
Brand Preferred$26,723,291$34,360,271$25.4$32.628.5%6,2337,4485.97.119.4%7.6%
Brand None Preferred$12,882,954$15,233,287$12.2$14.518.2%2,1682,3122.12.26.6%10.9%
OTC$0$0$0.0$0.0N/A000.00.0N/AN/A
Missing$0$0$0.0$0.0N/A000.00.0N/AN/A
Total Rx$127,923,107$143,410,312$121.50$136.1312.0%1,481,5771,523,4981,4071,4462.8%9.0%

Total (Medical + Rx) $461,177,809 $492,827,845 $438 $468 6.8% 4,359,232 4,456,275 4,140 4,230 2.2% 4.5%

35f All Plans (Rolling 12)

All Plans (Rolling 12)
Plan Year [Year]
Due Date45 days following two months of run-off data.
All PlansOct 2019 - Sep 2020Oct 2020 - Sep 2021
Total Members (Apr - Mar)1,052,8381,053,476
MedicalOct 2019 - Sep 2020Oct 2020 - Sep 2021Oct 2019 - Sep 2020Oct 2020 - Sep 20212021/2020Oct 2019 - Sep 2020Oct 2020 - Sep 2021Oct 2019 - Sep 2020Oct 2020 - Sep 20212021/20202021/2020
Paid AmountPaid PMPMPaid TrendServiceService/1000 MembersService TrendUnit Cost Trend
Facility Inpatient$71,741,344$77,880,350$68$748.5%211,869213,3442012030.6%7.8%
Facility Inpatient Long Term Care$639,694$524,038$1$0-18.1%3,1312,42132-22.7%5.9%
Facility Inpatient Maternity$8,657,570$8,749,775$8$81.0%45,71643,1624341-5.6%7.0%
Facility Inpatient Medical$24,208,572$24,364,834$23$230.6%87,10888,15183841.1%-0.5%
Facility Inpatient Non Acute$250,223$229,746$0$0-8.2%7331,0651145.2%-36.8%
Facility Inpatient Surgical$37,985,284$44,011,958$36$4215.8%75,18178,54571754.4%10.9%
Facility Outpatient$112,077,447$114,678,642$106$1092.3%518,358499,697492474-3.7%6.1%
Facility Outpatient DME$44,018$47,467$0$07.8%706100-12.9%23.7%
Facility Outpatient Diagnostic Services$6,190,460$6,687,980$6$68.0%10,53111,07410115.1%2.7%
Facility Outpatient Dialysis$2,580,556$2,980,201$2$315.4%5,4026,3535617.5%-1.8%
Facility Outpatient ER$22,005,531$22,378,164$21$211.6%153,869151,088146143-1.9%3.6%
Facility Outpatient Home Health$320,361$341,257$0$06.5%3,7413,28543-12.2%21.3%
Facility Outpatient Other$2,538,270$2,443,957$2$2-3.8%16,39717,43616176.3%-9.5%
Facility Outpatient PT, OT, Speech Therapy$3,374,915$3,644,473$3$37.9%27,24728,01326272.7%5.0%
Facility Outpatient Pharmacy$2,611,813$2,743,727$2$35.0%44,99045,06143430.1%4.9%
Facility Outpatient Specialty Drugs$17,172,999$15,842,706$16$15-7.8%12,95415,132121416.7%-21.0%
Facility Outpatient Supplies and Devices$408,555$454,068$0$011.1%15,48913,2131513-14.7%30.3%
Facility Outpatient Surgery$54,748,534$57,045,381$52$544.1%227,599208,909216198-8.3%13.5%
Facility Outpatient Transportation$81,434$69,260$0$0-15.0%6972004.3%-18.5%
Laboratory Outpatient$11,478,788$13,367,896$11$1316.4%635,722675,2246046416.1%9.6%
Laboratory Outpatient Chemistry Tests$4,355,850$5,760,903$4$532.2%322,414320,776306304-0.6%32.9%
Laboratory Outpatient Other$3,517,695$4,192,719$3$419.1%263,267306,53625029116.4%2.4%
Laboratory Outpatient Pathology$3,605,244$3,414,273$3$3-5.4%50,04147,9124845-4.3%-1.1%
MHSA$9,301,038$10,216,660$9$109.8%99,079106,269941017.2%2.4%
Mental Health Inpatient$2,048,423$2,152,147$2$25.0%6,1146,407664.7%0.3%
Mental Health Office Visits$1,515,818$1,612,451$1$26.3%19,96520,99219205.1%1.2%
Mental Health Other Outpatient$3,950,025$4,602,485$4$416.4%53,73563,748516118.6%-1.8%
Substance Abuse Inpatient$780,330$781,567$1$10.1%2,1562,160220.1%-0.0%
Substance Abuse Office Visits$38,719$35,663$0$0-7.9%52647700-9.4%1.6%
Substance Abuse Other Outpatient$967,723$1,032,346$1$16.6%16,58312,4851612-24.8%41.7%
Other Professional Services$42,056,724$45,697,286$40$438.6%722,710769,2406867306.4%2.1%
Professional Chiropractic Services$2,240,756$2,267,902$2$21.2%73,96074,96770711.3%-0.1%
Professional DME$2,043,006$2,012,996$2$2-1.5%19,63421,33819208.6%-9.3%
Professional Diagnostic Services$3,326,851$3,382,138$3$31.6%54,35256,05052533.1%-1.4%
Professional Dialysis$75,728$86,397$0$014.0%37731900-15.4%34.8%
Professional Home Health$516,858$528,703$0$12.2%6,0046,111661.7%0.5%
Professional Injections$3,140,603$3,176,079$3$31.1%115,382124,9261101198.2%-6.6%
Professional Office Visits$8,627,551$10,501,417$8$1021.6%124,604150,29111814320.5%0.9%
Professional PT, OT, Speech Therapy$4,818,655$4,858,685$5$50.8%190,456188,123181179-1.3%2.1%
Professional Services Other$5,087,740$5,667,151$5$511.3%83,17083,0287979-0.2%11.6%
Professional Specialty Drugs$6,963,689$8,020,896$7$815.1%6,1496,586667.0%7.5%
Professional Supplies and Devices$2,457,710$2,785,060$2$313.3%44,94353,558435119.1%-4.9%
Professional Transportation$2,757,577$2,409,860$3$2-12.7%3,6793,943347.1%-18.5%
Physician Inpatient$10,020,457$10,293,091$10$102.7%41,89342,43240401.2%1.4%
Physician Non-Specialty Inpatient$3,629,661$3,601,679$3$3-0.8%13,85513,7421313-0.9%0.0%
Physician Specialty Inpatient$6,390,796$6,691,411$6$64.6%28,03828,69027272.3%2.3%
Physician Outpatient$47,425,621$47,379,308$45$45-0.2%467,140459,147444436-1.8%1.6%
Physician Non-Specialty ER$131,037$124,918$0$0-4.7%58248810-16.2%13.7%
Physician Non-Specialty Office Visits$19,087,948$18,977,554$18$18-0.6%244,611243,202232231-0.6%-0.0%
Physician Non-Specialty Outpatient Other$1,077,780$1,063,177$1$1-1.4%34,91132,0043330-8.4%7.6%
Physician Non-Specialty Outpatient Surgery$1,636,112$1,655,190$2$21.1%3,9493,66643-7.2%9.0%
Physician Specialty ER$1,905,433$1,903,573$2$2-0.2%8,9318,93388-0.0%-0.1%
Physician Specialty Office Visits$9,224,107$9,346,014$9$91.3%103,602102,5349897-1.1%2.4%
Physician Specialty Outpatient Other$3,369,762$3,398,210$3$30.8%42,49040,5284038-4.7%5.7%
Physician Specialty Outpatient Surgery$10,993,442$10,910,672$10$10-0.8%28,06427,7922726-1.0%0.2%
Radiology Outpatient$29,153,284$29,904,301$28$282.5%180,884167,424172159-7.5%10.8%
Radiology Outpatient CT Scans$4,283,033$4,129,768$4$4-3.6%14,61215,19014143.9%-7.2%
Radiology Outpatient MRIs$4,445,877$4,412,861$4$4-0.8%9,7109,40599-3.2%2.5%
Radiology Outpatient Mammograms$2,907,052$3,230,808$3$311.1%45,08132,0624330-28.9%56.3%
Radiology Outpatient Nuclear Medicine$3,221,936$2,996,850$3$3-7.0%6,1695,70965-7.5%0.5%
Radiology Outpatient Other$937,887$988,613$1$15.3%4,6004,615440.3%5.1%
Radiology Outpatient Therapeutic Radiology$4,385,553$5,379,736$4$522.6%10,0179,301109-7.2%32.1%
Radiology Outpatient Ultrasounds$4,509,739$4,185,021$4$4-7.3%25,95224,7112523-4.8%-2.5%
Radiology Outpatient X-Rays$4,462,208$4,580,643$4$42.6%64,74366,43161632.5%0.0%
Total Medical$333,254,702$349,417,533$317$3324.8%2,877,6552,932,7772,7332,7841.9%2.9%
Prescription DrugsOct 2019 - Sep 2020Oct 2020 - Sep 2021Oct 2019 - Sep 2020Oct 2020 - Sep 20212021/2020Oct 2019 - Sep 2020Oct 2020 - Sep 2021Oct 2019 - Sep 2020Oct 2020 - Sep 20212021/20202021/2020
Paid AmountPaid PMPMPaid TrendScriptsScripts/1000 MembersScripts TrendUnit Cost Trend
Prescription Drugs Mail Order$3,881,907$3,915,468$3.7$3.70.8%27,27427,37425.926.00.3%0.5%
Generic$1,501,389$1,507,657$1.4$1.40.4%23,72224,01922.522.81.2%-0.8%
Brand Preferred$2,172,475$2,213,676$2.1$2.11.8%2,9382,7192.82.6-7.5%10.1%
Brand None Preferred$102,295$116,684$0.1$0.114.0%1361500.10.110.2%3.4%
OTC$57,782$13,018$0.1$0.0-77.5%198950.20.1-52.0%-53.0%
Missing$47,964$64,433$0.0$0.134.3%2803910.30.439.6%-3.8%
Prescription Drugs Retail$82,362,028$87,193,968$78.2$82.85.8%1,443,4761,483,5361,371.01,408.22.7%3.0%
Generic$32,109,767$35,246,837$30.5$33.59.7%1,285,5311,326,8381,221.01,259.53.2%6.4%
Brand Preferred$43,841,478$44,824,134$41.6$42.52.2%139,110133,831132.1127.0-3.9%6.3%
Brand None Preferred$5,845,828$6,170,639$5.6$5.95.5%12,71311,44312.110.9-10.0%17.3%
OTC$409,678$287,216$0.4$0.3-29.9%4,0295,3893.85.133.7%-47.6%
Missing$155,277$664,218$0.1$0.6327.5%2,0936,0332.05.7188.1%48.4%
Prescription Specialty Drugs$41,679,172$52,300,875$39.6$49.625.4%10,82712,58810.311.916.2%7.9%
Generic$2,072,927$2,707,317$2.0$2.630.5%2,4262,8282.32.716.5%12.0%
Brand Preferred$26,723,291$34,360,271$25.4$32.628.5%6,2337,4485.97.119.4%7.6%
Brand None Preferred$12,882,954$15,233,287$12.2$14.518.2%2,1682,3122.12.26.6%10.9%
OTC$0$0$0.0$0.0N/A000.00.0N/AN/A
Missing$0$0$0.0$0.0N/A000.00.0N/AN/A
Total Rx$127,923,107$143,410,312$121.50$136.1312.0%1,481,5771,523,4981,4071,4462.8%9.0%

Total (Medical + Rx) $461,177,809 $492,827,845 $438 $468 6.8% 4,359,232 4,456,275 4,140 4,230 2.2% 4.5%

File details come from the government source that posted it. Updated .