70-71 / 148
II. High Cost Claimant Summary
Plan Year: January 1, 2016 - December 31, 2016
ABC Company
6 Month Reporting Period: January 1, 2016 - June 30, 2016
A. High cost claimants
—
Claimants Exceeding $100,000 (UHC claims only; Does not include Express Scripts claims)
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sep 16
Oct 16
Nov 16
Dec 16
Claimant 1 - QHDHP
$0
$0
$0
$185,800 $12,262
$10,578
Cumulative = $208,639
$0
$0
$0
$185,800
$198,061
$208,639
Claimant 2 - High
$0
$0
$0
$74
$169,490 $13,621
Cumulative = $183,185
$0
$0
$0
$74
$169,563
$183,185
Claimant 3 - Base
$1,022
$379
$10,821
$64,373
$49,472
$18,583
Cumulative = $144,650
$1,022
$1,401
$12,222
$76,595
$126,067
$144,650
Claimant 4 - QHDHP
$11,791
$26,770
$23,471
$24,719
$24,332
$24,770
Cumulative = $135,852
$11,791
$38,560
$62,031
$86,750
$111,082
$135,852
Claimant 5 - Base
$3,394
$5,330
$3,107
$2,107
$853
$107,896
Cumulative = $122,686
$3,394
$8,724
$11,831
$13,938
$14,791
$122,686
Claimant 6 - High
$41
$4,909
$13,704
$93,260
$2,516
$741
Cumulative = $115,171
$41
$4,950
$18,654
$111,914
$114,430
$115,171
Claimant 7 - High
$5,482
$30,731
$8,417
$49,600
$15,451
$2,100
Cumulative = $111,781
$5,482
$36,213
$44,630
$94,230
$109,681
$111,781
Claimant 8 - QHDHP
$0
$0
$0
$0
$9
$105,149
Cumulative = $105,158
$0
$0
$0
$0
$9
$105,158
Claimant 9 - High
$9,804
$11,928
$14,669
$27,741
$13,148
$22,795
Cumulative = $100,086
$9,804
$21,733
$36,402
$64,143
$77,291
$100,086
Month represents the month claims were paid , not the month they were incurred. There is generally a one to two month lag between when claims are incurred and when they
are paid.
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