School District Learns PPO Allowed = 338% of Medicare

Interesting results of a claim study on the Edinburg Independent School District’s self-funded health plan several years ago show the Medicare equivalent reimbursement rates compared to the district’s PPO allowed amount.

This claim study was for a mature period of 12 months and encompass all hospital encounters. The following includes a mix of in-patient and out-patient encounters:


Doctors Hospital at Renaissance  244%

South Texas Health Systems  307%  

Rio Grande Regional   156%  

So. Texas Regional Medical Center  710%  

Valley Regional   383%  

M.D. Anderson  558%

The average paid amount in the aggregate was 338% of Medicare.

Meanwhile, down the road about 30 minutes away are two small school district totalling 900 employees are on a Reference Based Pricing plan. Their members go to many of the same hospitals and doctors as the Edinburg ISD members. But the cost difference is stark. These two itty bitty districts pay 120% of Medicare, about 2/3 less than the 4,500 pound Edinburg gorilla.