RD374 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2013


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, 2012 through June 30, 2013. 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 2013, the Ombudsman’s team handled 5,540 formal case-specific inquiries and reviewed 107 formal appeals. The team achieved its goal of continuous improvement by:

• working to resolve issues and solve problems in a timely manner,
• consistently analyzing issues, identifying emerging trends and working to correct systemic issues,
• updating policies and implementing new channels of communications, and
• making every effort to maximize the accessibility and effectiveness of the Health Benefits Program.

Some of the major projects managed during this fiscal year include:

• 2013-2014 Health Benefits Plans - the Ombudsman worked extensively with other DHRM employees to restructure the health plan options and benefits. The project included procuring services for administration of self-insured plan options, flexible spending accounts, a fully-insured Health Maintenance Organization (HMO), and a total health management program. Along with developing incentives to encourage health behaviors among the plan participants, the team worked on the development and implementation of:

o COVA HealthAware, a new Consumer Directed Health Plan,
o ALEX, an online health plan counseling tool, and
o MyActiveHealth, an integrated health and wellness management program.

• Affordable Care Act Provisions – The Ombudsman worked with other DHRM employees to review and implement required provisions of the Affordable Care Act (ACA) during this fiscal year and continues to work on provisions which will be implemented on or before July 2014. These include:

o Women’s Preventive Coverage - providing certain preventive care services at no cost to members,
o Flexible Medical Spending Account - capping the maximum contribution to the Commonwealth’s medical spending account at $2,500,
o Full-time Employee Definition - Guidelines for agencies to determine which employees qualify as full-time employees under the ACA 30 hour rule, and
o Summary of Benefits and Coverage –The Ombudsman and team worked with the plan vendors to develop twenty-four (24) summaries for the State and The Local Choice health plan to help members compare and understand their options.

• Disease Management Reporting and Coaching Pilot Program – the Ombudsman and team members worked with a specialized vendor and designated state agencies to implement and monitor this pilot program designed to alert participants of their risks for heart disease, stroke, and diabetes, providing comprehensive coaching as needed. Pilot program details and outcomes will be included in next year’s report.

• The Local Choice (TLC) Eligibility Migration – the Ombudsman and team worked with the TLC program manager and the OHB systems team to incorporate the eligibility and enrollment data for over 320 TLC groups, representing more than 31,000 school and municipal employees, into the Commonwealth’s Benefits Eligibility System (BES).

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