Summary: Exhibit J - Large Claims 2022-2024 Analysis

This is a financial claims exhibit document prepared for Volusia County Government's self-funded group health plan, detailing large individual claimant payments exceeding $150,000 across three fiscal years (2022-2024). The document presents comprehensive claims data organized by year, identifying 27 claimants in 2022, 44 claimants in 2023, and 45 claimants in 2024, with monthly payment distributions throughout each year. Notable high-cost claimants include cases involving Lennox-Gastaut Syndrome ($1,656,710 in 2024), epilepsy-related conditions, malignant neoplasms across various sites, sepsis, end-stage renal disease, cardiac conditions, and other serious chronic and acute conditions. The 2024 data shows total claimant payments of $12,114,442 for the year-to-date period, while 2023 totaled $12,094,915 and 2022 totaled $8,226,390, with monthly payment distributions indicating peak expenditures in the first and second quarters of each year.

The claims data reflects a Per Member Per Month (PMPM) cost of $254.05 for the current plan year and demonstrates significant utilization of stop-loss coverage mechanisms. The document includes monthly payment breakdowns (202301-202312 representing January through December) for individual high-cost cases, enabling the county to identify cost drivers and trending patterns for plan management and actuarial analysis. This exhibit serves as critical supporting documentation for the Administrative Services Only (ASO) contract procurement, providing prospective vendors with historical claims experience and enabling cost projections and reserve calculations for the proposed January 1, 2027 contract effective date. The data demonstrates the county's substantial self-funded health plan exposure and the necessity for comprehensive claims administration and utilization management capabilities from the selected vendor.