Board approves up to $4.9M to cover self-funded health-plan shortfall; district expects $2M aggregate reimbursement

Comal ISD trustees approved a motion Thursday to allocate up to $4,900,000 to cover claims that exceeded premiums in the district’s partially self-funded health plan for the 2024–25 plan year.

Eric Smith of Universal Benefits Consortium (UBC) and Mark Woolery, UBC managing director, told trustees their analysis showed an unusually large increase in high-cost claims late in the plan year. The consultants said there were 49 claimants with individual costs above $100,000 (up from 37 the prior comparable period) and that specialty pharmacy now accounts for about 75 percent of the district’s pharmacy spend. Smith said medical per-member-per-month costs rose roughly 26 percent year over year and pharmacy costs rose roughly 32 percent.

UBC explained the district has an aggregate stop-loss mechanism with an attachment point staff described as approximately $18,600,000; the consultants said the plan year claims are expected to exceed that threshold and result in an aggregate reimbursement to the district of about $2,000,000. That reimbursement is expected after claims are reconciled; staff said the plan must fund the claims first and then receive the stop-loss reimbursement.

Consultants and staff described steps taken to address costs for the coming plan year. The district said it negotiated a new pharmacy benefit manager and expected savings after repricing top specialty drugs; a preliminary repricing of the top 15 specialty drugs showed roughly $675,000 in savings and staff estimated eventual savings may exceed $1 million. Additional vendor programs — including a maternity-management program and Patient’s Choice (a value-driven provider network for imaging and ambulatory procedures) — were added to reduce future spend.

UBC warned trustees the deficit outlook for the coming year depended on whether high-cost claimants persisted. They provided a range of projected deficits: about $1.3 million if large-claimant activity normalizes, up to about $3.5 million if current utilization continues. Trustees approved the requested allocation to fund unpaid claims, and staff said they will seek the anticipated aggregate reimbursement when reconciliation is complete.