Edinburg CISD insurance manager warns rising high-cost claims driving plan losses

Dustin Garza, the district’s insurance manager, told the Edinburg CISD Board on Wednesday that medical and pharmacy costs have surged in recent years, driven largely by a rising number of very high-cost claimants. He said 169 plan members in the 2025 plan year accounted for roughly 45.5% of the district’s medical and pharmacy expenditures on a plan with about $56 million in annual costs.

"In two years, that category has risen 100 percent," Garza said, explaining the sharp increases in cancer-related treatments and newer, costly immunotherapies. He added that 14 people surpassed the district’s stop‑loss threshold of $350,000 and generated $8.45 million in incurred claims through December 31, some of which the stop‑loss carrier has started to reimburse.

Trustees pressed Garza on outreach and options to reduce costs. Board members asked whether staff had adequately explained new plan designs during open enrollment; Garza said district staff and insurance committee volunteers held enrollment sites and Google meetings, provided flip charts and a provider‑lookup link, and made plan comparisons available to enrollers.

Board members and Garza discussed several potential levers to control costs, including returning to a consultation on international pharmacy options, narrowing formularies to increase rebates (at the cost of access to some medicines), adding coinsurance for certain drugs, and creating a district clinic for employees. Garza cautioned that some changes would reduce employee access or require cultural adjustments among staff but said the district must be “acceptable to change” to remain financially sustainable.

The presentation included historical charts of enrollment, premiums and claim distributions. Garza recommended options and said staff can present specific proposals if trustees provide direction. The board asked for more targeted reports, including urgent‑care vs. emergency‑room usage by staff, and follow‑up outreach to better educate employees about available benefits.

Trustees did not take formal action on plan design during the meeting; Garza said staff will return with more detailed proposals and that the insurance committee will be reengaged for broader outreach and education.