RD380 - Report of the State Corporation Commission on the Activities of the Office of the Managed Care Ombudsman - 2009


Executive Summary:
The Office of the Managed Care Ombudsman (the Office) was established in the State Corporation Commission's Bureau of Insurance (the Bureau) on July 1, 1999, in accordance with § 38.2-5904 of the Code of Virginia. This report is submitted pursuant to § 38.2-5904 B 11, which requires the Office to submit an annual report of its activities to the standing committees of the Virginia General Assembly having jurisdiction over insurance and health, and also to the Joint Commission on Health Care. This is the eleventh annual report of the Office and covers the period from November 1, 2008 through October 31, 2009. Previous reports may be viewed on the Bureau of Insurance's website at:

www.scc.virginia.gov/division/boi/webpages/boiombudmanreports.htm

The legislation that created the Office authorizes it to assist consumers whose health insurance is provided by a Managed Care Health Insurance Plan (MCHIP). This includes all health maintenance organizations (HMOs), preferred provider organizations (PPOs) and other forms of insured managed care coverage. In order for the Office to assist a consumer formally, the coverage must be fully insured and issued in Virginia by a company licensed by the Bureau. Within these parameters, the coverage can be a group health insurance policy, coverage issued in the individual market, or individual coverage. Generally, if a consumer's health insurance coverage is subject to the regulatory jurisdiction of the Bureau, the Office can assist the consumer. Commensurate with the regulatory jurisdiction of the Bureau, the Office is unable to formally help consumers whose coverage is provided by any of the following:

• Federal government (including Medicare)
• State government (including Medicaid recipients)
• Self-insured plans established by employers to provide coverage to their employees; and
• Managed care plans when the coverage is issued outside of Virginia

Although the Office does not have the regulatory authority to assist consumers whose health insurance is provided by one of the above, the staff provides general information and advice, and may be able to refer these consumers to a federal or state regulatory agency for assistance. As part of its general consumer educational efforts, the Office helps these individuals understand how their health insurance is structured and explains why their health insurance is not subject to regulatory oversight by the Bureau.