RD366 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2012

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, 2011 through June 30, 2012. 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.

In fiscal year 2012, the Ombudsman’s team handled 5,142 formal case-specific inquiries and reviewed 113 formal appeals. The team achieved its goal of continuous improvement by:

• working to resolve issues and solve problems as they arose,
• consistently analyzed issues, paying particular attention to emerging trends,
• worked to update policies and communications related to the issues,
• carefully examining the facts to identify and correct systemic issues,
• and making every effort to maximize the accessibility and effectiveness of the Health Benefits Program.

Key interventions during this fiscal year include:

• The Health Benefits Appeals Process - the Ombudsman worked extensively with the appeals examiner to ensure that the appeals process for the program was compliant with the provisions for appeal reviews in the federal Affordable Care Act (ACA). In doing so, the Ombudsman and health benefits team accomplished the following:

o Worked with DHRM staff to secure the services of additional independent review organizations.
o Updated the state regulations.
o Revised plan member handbooks and web resources with the updated appeals review process.
o Coordinated with the plan administrators and review organizations to ensure their procedures were compliant with the state’s program and their communications reflected the new process.

• Commonwealth Wellness, Preventive Care & Incentive Programs – The team assisted with the plan administrators and DHRM management to analyze the outcomes of the various wellness, disease management and incentive programs within the health plan. Special projects included:

o A comparison of the Commonwealth’s health program with the health benefits programs for several other states,
o Participation in a Wellness Panel Discussion with other state governments, and
o The implementation of a Diabetes Management Incentive for the state’s program.

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

• Dependent Eligibility Definition – With the revision of the “eligible dependent child” definition under the program, the team worked to ensure communications were updated and responded to numerous inquiries regarding the implementation of this provision of federal health care reform.

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.