LaSalle County committee told major health-plan renewal increases driven by high-cost claims, stop‑loss and pharmacy trends

LaSalle County Insurance Committee members heard at length on Wednesday that next year’s health‑plan renewal will be unusually difficult because claims are running hotter than underwriter assumptions and stop‑loss and pharmacy costs are rising.

Mike, a Horton Group consultant, told the committee the plan is running about 106.7% of expected costs through July, with an actual per‑capita cost of about $25,040 versus an underwriter expectation of $23,004.63. “It is definitely been a difficult year, and we're going into a difficult renewal cycle,” Mike said, citing large claimants and broad market pressure.

The consultants’ report showed 12 large claimants above $75,000 so far in the plan year; the county’s specific deductible is $150,000. Horton Group said those cases, plus claimants above $50,000, are the primary drivers of the year‑to‑date cost increase. Horton estimated the plan’s employer responsibility on the large claim cohort at roughly $1.08 million and said the carrier had reimbursed about $445,000 to date.

Horton Group also flagged rapid growth in pharmacy specialty costs. Beth, a Horton Group consultant, said GLP‑1 medications (drugs commonly known by brand names such as Ozempic and Wegovy) and high‑cost biologics such as Humira are materially affecting pharmacy spend. “These drugs are finding ways to treat more and more things,” Beth said, noting that most carriers currently limit GLP‑1 coverage to diabetes diagnoses rather than obesity alone.

The consultants presented carrier and stop‑loss market responses. An initial Blue Cross renewal and competing proposals showed large moves in fixed costs: Horton said the quoted stop‑loss specific premium is increasing substantially (an initial quote climbing from about $2.49 to $3.73 in the vendor worksheet, which Horton described as nearly a 50% increase) and that mature, run‑in adjustments put a comparable mature specific premium near $359 per employee per month in one modeling example. Horton warned some quotes are on 12/12 contracts (short initial terms) and must be “matured” to reflect full run‑out exposure before a final price is firm.

Consultants emphasized pharmacy benefit manager (PBM) negotiations as the key lever to reduce the renewal increase. Horton’s PBM analysis showed Prime/Magellan or other PBM proposals could materially raise estimated rebates compared with Blue Cross’s initial rebate assumptions. “Clearly, your counterpart is willing to give us $846,000 in rebates. So why are you going down in rebates?” Beth asked, pointing at the carrier‑supplied worksheet.

Horton recommended more time to finalize best‑and‑final offers and warned reinsurance/stop‑loss markets wanted another month of claims data before firming quotes. The committee did not take a final vote on the active medical renewal at the meeting; Horton and committee members agreed to continue negotiation and reconvene in September. Several members asked about timing and whether an extra meeting prior to the regular September session would be needed to consider final offers.

Discussion vs. decision: the consultants presented analysis and market options (discussion); staff and consultants were directed to continue market negotiation and return with firm numbers (direction); there was no formal approval of the main medical renewal (formal decision deferred).

Ending: Committee members approved several stand‑alone items (see separate article on vision and HealthJoy). The committee scheduled follow‑up negotiation work and set a September 12 meeting to review updated renewal numbers.