What Are Plan Claims?

When reviewing financial or aggregate reports in the Yuzu system, you may notice a difference between medical + pharmacy claims totals and the total claims amount. This difference is made up of what Yuzu refers to as “plan claims.”

What Plan Claims Are

Plan claims are legitimate claim expenses that count toward the aggregate stop-loss factors but are not tied to a specific member’s medical or pharmacy claim. These costs are part of running the plan and must be included in overall claim calculations.

Common Examples of Plan Claims

• Direct Primary Care (DPC) ancillary fees – administrative or access fees tied to DPC programs.
• PBM administrative fees – charges related to pharmacy benefit management operations.
• Shared savings payments – amounts tied to savings programs, typically when a lower-cost provider or service is used.

Why Plan Claims Matter

Plan claims are included in the aggregate claims total because they represent real plan expenses that impact stop-loss performance and funding calculations. If they weren’t counted, the aggregate report would understate total plan costs.

Example

Suppose your Medical + Rx detail reports total $580,742.43, but the Aggregate Report shows $635,544.74.

The difference ($54,802.31) is composed of plan claims such as DPC ancillary fees, PBM admin fees, and shared savings.

This difference is expected and should be included in your financial calculations.