RD423 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2015


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, 2014 through June 30, 2015. 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 members in using available health plan resources.

In fiscal year 2015, the Ombudsman’s team handled 7,480 cases and reviewed 104 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.

Key initiatives and projects managed during this fiscal year include:

• 2014-2015 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, MyActiveHealth. In order to encourage healthy behaviors among health plan participants, the Ombudsman and OHB team members developed additional incentives for the health and wellness management program. The team also modified the process to qualify for the premium rewards program, and worked on plan year updates to ALEX, the health benefits program online counseling tool. Working with members of the OHB Policy Team, the Ombudsman assisted in the development of member communications and handbooks and the team worked on the benefit and claims resolutions for all plans.

• Same Sex Marriage and State Health Benefits - With the ruling to recognize same sex marriage in the Commonwealth of Virginia, employees and other participants eligible for state health benefits who became legally married were allowed to submit their request to enroll or add their spouse and other eligible dependents within sixty days of their marriage. The Office of Health Benefits provided letters to all health care eligible employees and participants with information on the required documentation and election request deadlines to assist with the enrollment process.

• 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 include:

* Mandate for reporting health care enrollment for plan members.
* Health Benefits for “Full-time” employees as defined by the ACA.
* Summary of Benefits and Coverage (SBC) for the available State and The Local Choice (TLC) health plans to help members compare and understand the options.
* IRC Section 125 regulation change which now allows employees to request a waiver of their enrollment in employer-sponsored plans to enroll in a health plan offered through the Marketplace Exchange.

• FAMIS Eligibility –New eligibility criteria became effective on January 1, 2015, for the FAMIS, the Children’s Health Insurance Program for the Commonwealth administered by the Department of Medical Assistance Services (DMAS). This change in eligibility allowed children of state employees, who met certain income criteria, to qualify for coverage under the FAMIS program. Employees could make changes to their health plan elections during the annual Open Enrollment period to enroll eligible children in FAMIS. DHRM worked with DMAS to provide information to the agencies and state employees about the new FAMIS eligibility and to include information about the DMAS qualification and enrollment process with the State’s Open Enrollment materials.

• Anthem Cyberattacks – The Ombudsman, Privacy Officer and key DHRM staff worked closely with Anthem on several reported data breaches. The most notable was the announcement of the Anthem nationwide cyberattack in February 2015, which affected current and former Anthem members and employees. The information accessed included names, Social Security numbers, addresses, and for Anthem employees, employment information and income data. Anthem set up a website and a toll-free number to respond to member questions. DHRM provided informational updates to employees and retirees during the investigation and addressed member concerns and issues with Anthem.

• Benefits Administrator Webinar Series - In an effort to provide tools for Benefits Administrators to expand their knowledge about health plans and other benefits available to their employees, the Office of Health Benefits worked with the plan administrators to coordinate and implement a series of webinars. The webinars were designed to better equip the benefits administrators to communicate the unique features of the plans to current and newly-eligible participants.

• The University of Virginia at Wise – Although the employees and early retirees of the University of Virginia are covered by a separate health plan administered through the University, the employees of the UVA - College at Wise were a part of the state employee health plan administered by DHRM. The University of Virginia was given approval to include the employees of the University of Virginia’s College at Wise in the UVA health plan. Although the College at Wise only had about 300 employees, the Office of Health Benefits provided necessary utilization and financial data, as well as input on communications, to UVA in an effort to make the transfer as seamless as possible for the employee population.

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