January 2023 - December 2024MedicalExperienceABC Company
2TOTAL MEDICAL & PHARMACY
3ABC COMPANY: TOTAL MEDICAL & PHARMACY
4TOTAL MEDICAL & PHARMACYKey Observations:• Current Plan YTD PEPM costs are up 27.3% over Prior Period driven by:• Increased Medical spend (15.5% above prior)• Increased Rx spend (65.4% above prior)• November 2024 is the highest month in the Current Period, with PEPM costs 36.8% above average driven by: • Increased Medical spend (24.0% above average)• Increased Rx spend (65.7% above average)Current Plan Year: January 2024 – December 2024Current Plan Year: January 2023 – December 2023
5Current vs. Prior Claims Change:• Plan Year through December 2024:Total Claims Change: -1.1%• Net Medical Claims: -10.2%• Rx Claims: +28.5%PEPM Claims Change: +27.3%• Net Medical Claims: +15.5%• Rx Claims: +65.4%• The difference between Total Claims Change vs. PEPM Claims Change is due to a 22.3% decrease in average enrollmentAverage enrollment:• Current Period: 161• Prior Period: 207Current Plan Year: January 2024 – December 2024Current Plan Year: January 2023 – December 2023TOTAL MEDICAL & PHARMACY
6TOTAL MEDICAL & PHARMACY – BUDGET DETAILJanuary 2023 - December 2024Period Enrollment Claims Total Loss Ratio PEPMMonth EEs Members Gross Medical Claims* Gross Rx Claims Pooled Claims Claims Premium Claims ÷ Premium Claims ÷ EEs2023-01 Plan YearJan 2023196 412 $201,855 $65,375 ($91,082)$176,148 $280,826 62.7%$898.72 Feb 2023202 431 $134,969 $56,844 ($62,055)$129,758 $288,448 45.0%$642.36 Mar 2023208 442 $220,007 $71,182 ($88,559)$202,630 $300,397 67.5%$974.18 Apr 2023211 452 $192,292 $61,354 ($53,535)$200,111 $307,782 65.0%$948.39 May 2023215 464 $162,049 $88,441 ($52,316)$198,174 $309,284 64.1%$921.74 Jun 2023215 469 $213,693 $73,601 ($60,025)$227,269 $312,653 72.7%$1,057.07 Jul 2023220 475 $496,222 $66,235 ($120,844)$441,613 $318,516 138.6%$2,007.33 Aug 2023226 488 $233,188 $77,072 ($66,423)$243,836 $328,054 74.3%$1,078.92 Sep 2023224 482 $248,084 $62,775 ($59,162)$251,697 $319,735 78.7%$1,123.65 Oct 2023208 456 $151,605 $84,360 ($48,121)$187,845 $304,857 61.6%$903.10 Nov 2023181 401 $270,966 $82,469 ($77,056)$276,379 $272,427 101.5%$1,526.95 Dec 2023177 392 $252,294 $70,565 ($62,643)$260,216 $264,068 98.5%$1,470.15 2023-01 Plan Year Total207 447 $2,777,224 $860,273 ($841,821)$2,795,675 $3,607,046 77.5%$1,125.93 2024-01 Plan YearJan 2024169 375 $191,701 $84,666 ($54,720)$221,646 $283,529 78.2%$1,311.52 Feb 2024168 373 $210,991 $38,174 ($53,818)$195,348 $281,263 69.5%$1,162.78 Mar 2024168 373 $210,644 $93,010 ($56,892)$246,762 $283,868 86.9%$1,468.82 Apr 2024168 365 $147,240 $53,216 $0 $200,456 $277,380 72.3%$1,193.19 May 2024169 364 $165,717 $67,460 $0 $233,178 $278,858 83.6%$1,379.75 Jun 2024164 356 $216,574 $51,202 $0 $267,776 $274,770 97.5%$1,632.78 Jul 2024162 353 $110,254 $70,209 $0 $180,463 $269,544 67.0%$1,113.97 Aug 2024156 340 $207,188 $89,280 $0 $296,468 $260,623 113.8%$1,900.43 Sep 2024154 337 $119,203 $73,863 $0 $193,067 $259,184 74.5%$1,253.68 Oct 2024152 324 $85,706 $71,561 $0 $157,267 $250,647 62.7%$1,034.65 Nov 2024150 322 $184,923 $109,256 $0 $294,180 $245,678 119.7%$1,961.20 Dec 2024149 321 $190,222 $88,317 $0 $278,538 $247,310 112.6%$1,869.38 2024-01 Plan Year Total161 350 $2,040,363 $890,214 ($165,430)$2,765,147 $3,212,654 86.1%$1,433.46 Prior Plan YTD (PEPM)207 447 $1,118.50 $346.47 ($339.03)$1,125.93 $1,452.70 77.5%Current Plan YTD (PEPM)161 350 $1,057.73 $461.49 ($85.76)$1,433.46 $1,665.45 86.1%% Change(22.3%)(21.6%)(5.4%)33.2%(74.7%)27.3%14.6%
7TOTAL MEDICAL & PHARMACY – CLAIM DETAILJanuary 2023 - December 2024Period Enrollment ClaimsMonth EEs Members Gross Medical Claims Gross Rx Claims Capitation HRA Claims Pooled Claims Claims2023-01 Plan YearJan 2023196 412 $173,440 $65,375 $2,952 $25,464 ($91,082)$176,148 Feb 2023202 431 $112,925 $56,844 $3,218 $18,825 ($62,055)$129,758 Mar 2023208 442 $191,390 $71,182 $3,377 $25,240 ($88,559)$202,630 Apr 2023211 452 $170,648 $61,354 $3,260 $18,384 ($53,535)$200,111 May 2023215 464 $138,280 $88,441 $3,457 $20,312 ($52,316)$198,174 Jun 2023215 469 $186,528 $73,601 $3,677 $23,487 ($60,025)$227,269 Jul 2023220 475 $462,014 $66,235 $3,806 $30,401 ($120,844)$441,613 Aug 2023226 488 $210,786 $77,072 $3,625 $18,776 ($66,423)$243,836 Sep 2023224 482 $210,395 $62,775 $3,480 $34,209 ($59,162)$251,697 Oct 2023208 456 $124,897 $84,360 $3,397 $23,312 ($48,121)$187,845 Nov 2023181 401 $255,296 $82,469 $2,892 $12,778 ($77,056)$276,379 Dec 2023177 392 $229,344 $70,565 $2,692 $20,258 ($62,643)$260,216 2023-01 Plan Year Total207 447 $2,465,941 $860,273 $39,835 $271,448 ($841,821)$2,795,675 2024-01 Plan YearJan 2024169 375 $154,353 $84,666 $2,841 $34,506 ($54,720)$221,646 Feb 2024168 373 $199,136 $38,174 $2,800 $9,055 ($53,818)$195,348 Mar 2024168 373 $183,248 $93,010 $2,750 $24,646 ($56,892)$246,762 Apr 2024168 365 $144,399 $53,216 $2,841 $0 $0 $200,456 May 2024169 364 $162,867 $67,460 $2,851 $0 $0 $233,178 Jun 2024164 356 $213,711 $51,202 $2,863 $0 $0 $267,776 Jul 2024162 353 $107,414 $70,209 $2,840 $0 $0 $180,463 Aug 2024156 340 $204,359 $89,280 $2,829 $0 $0 $296,468 Sep 2024154 337 $116,335 $73,863 $2,868 $0 $0 $193,067 Oct 2024152 324 $82,804 $71,561 $2,902 $0 $0 $157,267 Nov 2024150 322 $182,013 $109,256 $2,910 $0 $0 $294,180 Dec 2024149 321 $187,349 $88,317 $2,872 $0 $0 $278,538 2024-01 Plan Year Total161 350 $1,937,990 $890,214 $34,166 $68,207 ($165,430)$2,765,147 Prior Plan YTD (PEPM)207 447 $993.13 $346.47 $16.04 $109.32 ($339.03)$1,125.93 Current Plan YTD (PEPM)161 350 $1,004.66 $461.49 $17.71 $35.36 ($85.76)$1,433.46 % Change(22.3%)(21.6%)1.2%33.2%10.4%(67.7%)(74.7%)27.3%
8TOTAL MEDICAL & PHARMACY –ENROLLMENT DETAILCurrent Period59.2% of enrolled employees elect dependent coveragePrior Period53.6% of enrolled employees elect dependent coveragePeriod Enrollment TotalMonth EE Only EE + 1 EE + Family Enrolled Members2023-01 Plan YearJan 202393 42 61 196 412 Feb 202394 43 65 202 431 Mar 202399 41 68 208 442 Apr 202399 42 70 211 452 May 2023101 41 73 215 464 Jun 202399 42 74 215 469 Jul 2023103 43 74 220 475 Aug 2023106 43 77 226 488 Sep 2023107 40 77 224 482 Oct 202394 40 74 208 456 Nov 202379 36 66 181 401 Dec 202377 35 65 177 392 2023-01 Plan Year Total96 41 70 207 447 2024-01 Plan YearJan 202468 42 59 169 375 Feb 202468 41 59 168 373 Mar 202467 41 60 168 373 Apr 202470 41 57 168 365 May 202471 42 56 169 364 Jun 202468 40 56 164 356 Jul 202466 41 55 162 353 Aug 202463 40 53 156 340 Sep 202461 40 53 154 337 Oct 202462 42 48 152 324 Nov 202462 39 49 150 322 Dec 202461 38 50 149 321 2024-01 Plan Year Total66 41 55 161 350 Prior Plan YTD (PEPM)96 41 70 207 447 Current Plan YTD (PEPM)66 41 55 161 350 % Change(31.6%)(0.2%)(22.4%)(22.3%)(21.6%)
9TOTAL MEDICAL & PHARMACY – FIXED COST DETAILPeriod EnrollmentMonth EEs Members2023-01 Plan YearJan 2023196 412 Feb 2023202 431 Mar 2023208 442 Apr 2023211 452 May 2023215 464 Jun 2023215 469 Jul 2023220 475 Aug 2023226 488 Sep 2023224 482 Oct 2023208 456 Nov 2023181 401 Dec 2023177 392 2023-01 Plan Year Total207 447 2024-01 Plan YearJan 2024169 375 Feb 2024168 373 Mar 2024168 373 Apr 2024168 365 May 2024169 364 Jun 2024164 356 Jul 2024162 353 Aug 2024156 340 Sep 2024154 337 Oct 2024152 324 Nov 2024150 322 Dec 2024149 321 2024-01 Plan Year Total161 350 Prior Plan YTD (PEPM)207 447 Current Plan YTD (PEPM)161 350 % Change(22.3%)(21.6%)
10HIGH-COST CLAIMANT (HCC) ACTIVITY >$50KThere are 5 claimants over the $100K pooling point.January 2024 Through December 2024Claimant Plan Relationship Status Medical Paid Rx Paid Total Claim AmountPooled ClaimsClaims through Prior MonthChange from prior month1 PPO Dependent ACTIVE $88,020 $266,454 $354,474 $254,474 $346,423 $8,052 2 PPO Subscriber ACTIVE $16,239 $165,051 $181,290 $81,290 $179,268 $2,022 3 PPO Subscriber CANCELLED $164,933 $97 $165,029 $65,029 $169,334 ($4,304)4 PPO Subscriber CANCELLED $117,313 $845 $118,158 $18,158 $147,911 ($29,753)5 PPO Spouse ACTIVE $112,390 $956 $113,345 $13,345 $112,951 $394 6 PPO Dependent ACTIVE $89,146 $51 $89,197 $0 $89,492 ($296)7 PPO Subscriber ACTIVE $6,477 $58,195 $64,672 $0 $64,734 ($62)8 HMO Subscriber ACTIVE $6,843 $54,783 $61,626 $0 $56,422 $5,204 9 PPO Subscriber ACTIVE $54,062 $3,459 $57,520 $0 $0 $57,520 10 PPO Spouse ACTIVE $56,568 $16 $56,584 $0 $56,588 ($4)11 HMO Subscriber ACTIVE $50,343 $5,100 $55,443 $0 $0 $55,443 Total $762,332 $555,007 $1,317,338 $432,297 $1,223,123 $94,216
11HCC PROGRESSION $50K
12HCC INCIDENCE LEVELS
13HIGH-COST CLAIMANT (HCC) ACTIVITY >$50KThere are 6 claimants over the $100K pooling point.January 2023 Through December 2023Claimant Plan Relationship Status Medical Paid Rx Paid Total Claim AmountPooled ClaimsClaims through Prior MonthChange from prior month1 PPO Dependent ACTIVE $131,895 $249,670 $381,564 $281,564 $396,497 ($14,933)2 PPO Spouse ACTIVE $282,306 $728 $283,033 $183,033 $283,379 ($345)3 PPO Subscriber ACTIVE $41,441 $140,852 $182,293 $82,293 $205,876 ($23,583)4 PPO Subscriber CANCELLED $155,004 $1,630 $156,634 $56,634 $156,634 $0 5 PPO Spouse CANCELLED $148,828 $72 $148,899 $48,899 $147,473 $1,426 6 PPO Subscriber ACTIVE $12,487 $109,575 $122,062 $22,062 $129,066 ($7,004)7 PPO Subscriber CANCELLED $90,162 $222 $90,384 $0 $86,643 $3,740 8 PPO Spouse ACTIVE $75,436 $802 $76,238 $0 $84,721 ($8,484)9 PPO Dependent CANCELLED $1,936 $64,024 $65,960 $0 $66,969 ($1,010)10 PPO Dependent CANCELLED $63,517 $1,156 $64,673 $0 $66,868 ($2,195)11 PPO Subscriber ACTIVE $48,981 $6,555 $55,536 $0 $0 $55,536 Total $1,051,992 $575,285 $1,627,277 $674,487 $1,624,128 $3,149
14HCC PROGRESSION $50K
15HCC INCIDENCE LEVELS
APPENDIX
17NotesAPPENDIX• ABC Company has a Fully Insured Medical Plan • Medical claims and large claim data are provided by BCBSMA• Pharmacy claims and rebate data provided by BCBSMA• Medical/Pharmacy Enrollment data provided by BCBSMA
18• Total Claims = Gross Medical Claims + Gross Rx Claims – SL Reimbursements• Net Medical Claims = Gross Medical Claims – SL Reimbursements• Net Rx Claims = Gross Rx Claims – SL Reimbursements• Plan Cost = Total Claims• Premium reported from invoice provided by BCBSMATerminologyAPPENDIX
DISCLOSURES
201. All figures are based upon the information available as of the report date. They are subject to change as more information is available. 2. The accuracy and reliability of this reporting depends on the quality and completeness of the input data. OneDigital has reviewed the data for reasonableness but has not audited the data.3. We strongly recommend that users review these results for reasonability. Users of this information should exercise their own judgment and seek professional advice when making decisions based on this report.4. Any estimate or projection may not be used or relied upon by any other party or for any other purpose than for which it was issued by OneDigital. OneDigital is not responsible for the consequences of any unauthorized use.5. Past performance or results do not guarantee future outcomes.6. OneDigital’s financial interests in this engagement are in no way tied to financial performance of ABC Company.By using or relying on the information presented in this document, you acknowledge and accept these limitations and disclaimers.EXPERIENCE REPORTING DISCLOSURES