RD509 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2016


Executive Summary:
This annual report on the activities of the Ombudsman for the Office of State and Local Health Benefits Programs (OHB) for the Virginia Department of Human Resource Management (DHRM) covers the period from July 1, 2015 through June 30, 2016. During this fiscal year, 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 members in understanding their benefits, as well as their rights, and the processes available through the program. The team also guided covered members in the utilization of available health plan resources.

In fiscal year 2016, the Ombudsman’s team handled 7,337 cases and reviewed 91 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:

• 2015-2016 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. The team worked to modify 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.

The State Corporation Commission’s Bureau of Insurance (BOI) handles complaints for fullinsured health plans for the Commonwealth. The Ombudsman and Appeals Examiner met with the BOI to discuss patterns and trends for services submitted as consumer complaints and appeals to both offices. The complaints identified the balance billing practices for out-of-network air ambulance providers and charges for non-covered durable medical equipment, in particular the Zoll Life Vest. Our team continues to work with the health plan vendors to develop a communication strategy aimed at educating both the provider community and members regarding these services.

• Capitol Square Healthcare - the Ombudsman, along with other DHRM employees, worked with Virginia Commonwealth University Health Systems (VCUHS) and QuadMed® to develop policies, procedures and communications for an onsite health and wellness clinic in the Capitol Square area. The new clinic, Capitol Square Healthcare, opened in May 2016 on the James Monroe Building’s Mezzanine.

• Independent Review Organizations – The Ombudsman and members of her team worked with the Director of Finance and Contracts to secure vendors to provide Independent Third Party Medical Review Services for the Health Benefits Program. The Request for Proposal (RFP) published October 19, 2015, required the submission of proposals by December 10, 2015. The proposals were reviewed, scored and negotiation sessions with the finalist conducted. The notice of our intent to award contracts to Maximus Federal Services Incorporated, Medical Consultants Network, and IPRO was issued on March 11, 2016.

• Local Option Health Plan - In 2016, SB 364(Chafin) was signed into law and directed DHRM to develop a local health plan option to operate with a single risk pool. The plan is being offered as an additional choice for schools, local governments and other political subdivisions. It will have one risk pool and one set of rates. Its benefit design will be similar to that of state employee health plans. The Ombudsman worked closely with the OHB policy team and Director on the ongoing development of the design and provisions of the plan which will be implemented in July 2018.

• 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. The Ombudsman and OHB team members worked with state agencies and local employer groups to update the information in our eligibility system to ensure the accuracy of the information included on the report to the IRS regarding enrollment in qualified health coverage mailing 1095C forms to approximately 150,000 state and local employees in March 2016.

* 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.

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.