Purpose and Availability
Aggregate reports are specific to a Group Policy (e.g. one sponsor and one plan year) but incorporate information about multiple plans. The purpose of the Aggregate report is to help the TPA file aggregate stoploss claims, although since the report has overall information about how the plan is performing, it is valuable to employers and brokers too.
You can view the Aggregate report at https://portal.yuzu.health/group/${id}/reports.
The report has all claims information, including claims paid for by the spec policy.
Definitions and Formulas to Know
Plan-Level Claims Paid
There are some fees that are covered under the aggregate stoploss policy but not under the specific stoploss policy. These are considered “Plan Claims” and are available in the portal on the Plan Claims tab https://portal.yuzu.health/group/${id}/plan-claims .
Here are some common examples of Plan Claims:
PBM admin fees.
DPC Ancillary fees (e.g. laboratory expenses that are billed across the whole group)
Retainage fees (some networks charge a “percent savings” on all claims).
Total Claims Paid
Total Claims Paid = Plan-Level Claims Paid + Medical Claims Paid + Pharmacy Claims Paid
Claims Over Spec
These are claims that are above a member’s spec. These are not reimbursable under the aggregate policy, and are calculated in order to be excluded from aggregate claims. This might not match the exact amount of specific claims filed or received, because we only periodically file stoploss claims but the aggregate report captures claims paid over spec in real time.
Rebates Received
Rebates are typically received 6 months after a reporting period ends. They are also not covered under aggregate stoploss. You can view rebates in the portal on the rebates tab. Not all rebates are literally paid to the plan, sometimes rebates are credited against other invoices paid to the PBM.
Out of Policy Claims
Out of policy claims are exceptions: things that the plan paid that are not covered by stoploss. These are viewable on the Claim Exceptions tab. These are rare and are confirmed with clients before paid.
Total Agg Adjustments
Total Agg Adjustments = Claims Over Spec + Rebates Received + Out of Policy Claims
Agg (Surplus) Deficit
Agg (Surplus) Deficit = Total Claims Paid - Attachment Point - Total Agg Adjustments (negative denotes employer surplus)
PTD Agg (Surplus) Deficit
Agg (Surplus) Deficit but cumulative plan-to-date (“PTD”)
PTD % of Attachment Point
PTD % of Attachment Point (Net Loss Ratio) = (Total Claims Paid - Total Agg Adjustments) / PTD Attachment Point