McAllen ISD staff propose single health plan, deductible increases and 340B mail-order program to address $4.8 million shortfall

McAllen ISD benefits staff on the district's budget team presented a plan to move employees onto a single medical plan, raise the individual deductible to $1,250 and pursue several plan-design and vendor strategies — including a mandatory mail-order option for eligible 340B prescriptions — intended to reduce a projected $4.8 million shortfall in the employee health fund.

The proposals are aimed at reducing program costs and shifting some expenses to utilizers. "We think it's relatively low impact with significant, savings in dollars. So it's one that we're recommending," said Mr. Silva, the district's benefits presenter, describing a 340B mail-order option that would initially affect 42 members and 156 prescriptions and could save roughly $250,000 annually.

Why it matters: the district projects roughly $30 million in medical costs next year and an estimated shortfall of about $4.8 million under current plan designs. Staff said a combination of changes — an employer contribution increase, employee premium adjustments, plan consolidation and targeted plan-design changes — could produce about $4.2 million in revenue and savings and move the fund to a projected $1.5 million positive balance if all modeled assumptions hold.

Key proposals and estimated fiscal effects - Consolidate to one plan: Staff recommended moving from three plans to a single basic plan to reduce high loss-ratio exposure in the higher-cost plans. That consolidation is estimated to produce about $3.5 million in savings. Staff said implementation timing would be Jan. 1, 2026, because plan design changes align with calendar-year benefits.

- Increase employer contribution: A proposed employer contribution increase of about $55 per employee per month would generate about $2 million in additional revenue and align district contribution levels with peer districts.

- Employee premium change: Under a one-plan model staff modeled a 15% across-the-board employee premium increase, producing roughly $155,000 in additional revenue while noting some employees who currently pay more would migrate into lower rates.

- Deductible and plan-design changes: Staff proposed raising the individual deductible from $1,000 to $1,250 (and a corresponding family increase), adding or adjusting a specialist copay and introducing an inpatient hospital copay. Those design changes were projected to save about $230,000.

- Specialty GLP‑1 tier: To address high-cost GLP‑1 medications (presenter identified Mounjaro as the primary current example), staff proposed a specialty coinsurance tier (30% cost-share). Staff said 12 members currently use the medication; the proposal could leave those members with an out‑of‑pocket impact “between $200 and $300” per fill before manufacturer assistance is applied. Staff noted many patients receive manufacturer discount or copay-assistance programs that often reduce the member’s immediate cost.

- 340B mail-order pharmacy program: Staff proposed leveraging a federal 340B mail-order pathway negotiated through the district's pharmacy benefit manager, Araya, as a way to lower costs for certain qualifying prescriptions. The program would require an annual telehealth consultation with a participating hospital pharmacist and, under the staff recommendation, would be a mandatory mail-order requirement for eligible drugs. Staff estimated 42 members currently would be impacted; the district could save an estimated $250,000 annually if utilization stays at current levels.

- Direct contracting and preferred local network: Staff said some local providers have expressed interest in negotiating directly with the district outside the third-party administrator (TPA) to create a preferred network and steerage incentives for employees; staff will invite formal solicitations if negotiations proceed.

Operational steps and timelines - Request for proposals: Staff plans to put medical and pharmacy administration RFPs in the market mid‑April, with a four‑week window and an award in August, aiming for final enrollment materials by Oct. 1 for Jan. 1 effective dates. Dental RFP work is also underway; the district currently pays about $18 per employee per month for basic dental and may need to adjust employer/employee splits if bids exceed that amount.

- Implementation dates: Some plan changes could be implemented July 1 with 60 days' notice (staff cited the specialty tier and the 340B mail-order transition as candidates for July 1), while full plan consolidation and calendar-year design changes are planned for Jan. 1, 2026.

What staff said about member impact and outreach Staff said many of the design changes would affect only utilizers rather than all employees and emphasized outreach and education. Mr. Silva described the 340B mail-order workflow: pharmacies would show a message requiring the mail-order program for qualifying drugs; Araya or the vendor would then assist enrollment and the annual pharmacist telehealth consultation.

"It's a requirement that when they fill that medication, you have to consult with the pharmacist," Mr. Silva said, describing the telehealth step for the 340B option.

Ms. Schulz, a staff member who answered utilization questions during the presentation, said the district sees a pattern where "20% of the employees are 80% of the cost," a common distribution that informed recommendations to target changes to high utilizers.

Uncertainties and risks Staff emphasized modeled savings are projections and depend on vendor responses to the RFP, actual utilization changes, and member acceptance of program shifts. They rated the changes as potentially disruptive for some members (for example, mandatory mail order for eligible drugs and added specialty tiers) but argued the overall member impact would be limited given currently small affected populations.

Ending: next steps Staff closed the presentation asking for board direction on pursuing the RFPs and implementation planning; no formal board action on plan design changes was recorded in the provided transcript. Staff said they would return with RFP results and additional detail before any final decisions affecting benefit design or member costs.