RD504 - Report on the Activities of the Office of the Managed Care Ombudsman Pursuant to § 38.2-5904 of the Code of Virginia – December 1, 2017

Executive Summary:

This annual report on the activities of the State Corporation Commission's ("SCC") Office of the Managed Care Ombudsman ("Office" or "Staff"), which is within the SCC's Bureau of Insurance ("Bureau"), covers the period November 1, 2016 to October 31, 2017. During this period, the Staff: provided information and formal assistance to more than 699 consumers and other individuals; responded to general questions and specific issues with managed care and health insurance coverage provided by managed care health insurance plans ("MCHIP"); assisted consumers in understanding how their health insurance plans work; emphasized the importance of reading and understanding health insurance coverage documents; and offered information on methods to resolve issues.

In total, the Staff responded to 567 inquiries and assisted 132 consumers filing appeals with MCHIPs because of adverse benefit determinations. When necessary, the Staff referred consumers to either another section of the Bureau for assistance or to another regulatory agency when the issue involved a regulatory matter outside of the Bureau's regulatory authority. The Staff also participated in outreach events and continued monitoring federal and state health insurance-related legislation. Details of these and other activities are provided herein.