RD358 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2011


Executive Summary:
This annual report on the activities of the Ombudsman for the Office of State and Local Health Benefits Programs (OHB) covers the period from July 1, 2010 through June 30, 2011. The Ombudsman’s team helped to resolve issues encountered by employees, retirees and their covered dependents involving access and eligibility for health care under the Commonwealth’s Health Benefits Program. As part of its responsibilities, the team assisted covered employees in understanding their rights and the processes available to them through the program. The team also guided covered employees in using available health plan resources, including all appeals procedures.

In fiscal year 2011, the Ombudsman’s team handled 5,014 formal case-specific inquiries and assisted with 75 formal appeals. The team achieved its goal of continuous improvement by working to resolve issues and solve problems as they arose and by carefully examining the facts to identify and correct systemic issues.

During FY 2011, the Ombudsman’s team has made many efforts to maximize the accessibility and effectiveness of the Health Benefits Program. The team consistently analyzed issues, paying particular attention to emerging trends. Key interventions for the Ombudsman’s team during this fiscal year include:

• Qualifying Midyear Events - The decision to modify the plan’s enrollment windows for qualifying mid-year events (QMEs) is expected to accommodate the needs of the employees and reduce the number of eligibility appeals for the program.

• Durable Medical Equipment - The Ombudsman assisted in the resolution of issues related to an adjustable appliance used to progressively mold the shape of the cranium resulting in the modification of the review criteria for the appliance.

• Communications – The Ombudsman worked on the development of communication directed to employees seeking assistance through the Virginia State Employee Loan Program.

• Customer Relationship Management (CRM) system - The team continued to work to further refine the CRM system designed to track and manage customer contacts.

• Appeals Process - The Ombudsman’s team worked to ensure that OHB’s appeals process would be compliant with health care reform in FY 2012.

The Ombudsman’s team continued to provide a service needed by state employees and retirees in accordance with the legislation that created the role in 2000.