RD426 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2014


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, 2013 through June 30, 2014. 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 2014, the Ombudsman’s team handled 9,158 formal case-specific inquiries and reviewed 73 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 and Programs - the Ombudsman continued to work with other DHRM employees on various components of the health plans, including a comprehensive health and wellness management program. Along with developing member communications and handbooks, the team worked on the benefit and claims resolutions for all plans due to:

• changes in claim administrators for the Preferred Provider Organization (PPO) and High Deductible Health Plan (HDHP),
• implementation of the new Consumer Directed Health Plan (CDHP),
• changes in the dental benefits structure,
• implementation of an integrated health and wellness management program, and
• implementation of a premium rewards program.

• Value Based Insurance Design (VBID) - The Commonwealth’s self-insured PPO and CDHP plans introduced several programs that rewarded members for completing healthy activities. These programs were designed to encourage the utilization of plan benefits, educate the members about their personal health risks, and provide members with options to manage health conditions and assist with tools to encourage changes in behavior.

• Disease Management Reporting and Coaching Pilot Program - Volunteers in a large statewide agency participated in a pilot program designed to provide individuals with detailed information about health risks associated with heart disease, stroke and diabetes by offering advance testing to identify hidden risk factors. The program provides each at-risk member with a personal health coach to assist with the development of a plan for health improvement. Members of the Ombudsman’s team provided the oversight of the pilot program with the Department of Behavioral Health and Developmental Services (DBHDS) and Health Diagnostic Laboratories, Incorporated(HDL).

• The Local Choice (TLC) Eligibility Migration - The Ombudsman and team continued work with the TLC program manager and the OHB systems team to incorporate the eligibility and enrollment data for the TLC groups into the Commonwealth’s Benefits Eligibility System (BES).

• Affordable Care Act Provisions - The Ombudsman worked with other DHRM employees on various provisions of the Affordable Care Act (ACA) during this fiscal year and continues work on future provisions. These provisions include:

• Summary of Benefits and Coverage –The Ombudsman and team worked with the plan vendors to develop new summaries for the State and The Local Choice health plan to help members compare and understand their options.
• Notification of the Marketplace Exchange – Coordinated the distribution of the notice which contains information about the Health Insurance Marketplace to all employees.
• Mandate for reporting employee health care enrollment.
• Health Benefits for “Full-time” employees as defined by the ACA.

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