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One Wellmark enrollee filed $18 million in 2015 claims

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Wellmark Blue Cross Blue Shield of Iowa says it spent $18 million on medical bills for just one patient in 2015.

Because the Des Moines, Iowa-based insurer began covering the patient July 1, 2015, the money went to pay for care delivered in the second half of the year.

Wellmark is now spending about $1 million a month on allowed claims for the patient, and it expects to spend about $10.5 million on allowed claims for the patient in 2017, the company says.

Actuaries at Magnum Actuarial Group, a New Berlin, Wisconsin-based firm hired by the Iowa Insurance Division to review a Wellmark individual rate filing for 2017, talk about the catastrophic health claim in the filing review. Based in part on the analysis, Iowa regulators ended up approving Wellmark’s request for a 42.6 percent rate increase for plans that now cover a total of about 21,900 people.

The one high-cost patient accounts for about 10 percentage points of the 2017 increase, according to a Des Moines Register article cited in the actuarial review.

In the article, a Wellmark executive described the patient as an “extremely complicated patient” who suffers from a “severe genetic disorder.”

The patient has a policy that complies with all Affordable Care Act coverage rules, according to the actuaries. The ACA now prohibits insurers from setting annual or lifetime limits on payments for what the ACA classifies as essential health benefits.

The complex patient added about $820 in claim costs per current plan enrollee, and the $10.5 million in projected 2017 claims could average about $500 in claim costs per 2017 enrollee.

For 2014, 2015 and 2016, the ACA provides a reinsurance fund to help insurers pay the bills of individual policy insureds with catastrophic claims, but the maximum amount of claims covered is just $250,000.

Wellmark assumed when it calculated the 2017 rate increase that its underlying cost of medical claims will rise 9 percent in 2017. When the company developed its rates for 2016, it assumed the underlying increase in trend would be just 5 percent.

The 2017 increase assumption is so high partly because, when Wellmark looked at its full results for 2015, it found that the patient with the $18 million in claims had contributed to an increase in allowed claims of either 17.9 percent or 18.5 percent, depending on the calculation method used, according to the Magnum actuaries.


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