RD518 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2017

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, 2016 through June 30, 2017. 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 2017, the Ombudsman’s team handled 7,923 issues and reviewed 125 formal appeals. The team continues to:

• resolve issues and solve problems in a timely manner;

• consistently analyze issues, identify emerging trends and work to correct systemic issues;

• update policies and provide meaningful communication to our customers; and

• make every effort to maximize the accessibility and effectiveness of the Health Benefits Program.

Key initiatives and projects managed during the fiscal year include:

• 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:

• Section 1557, Nondiscrimination in Health Programs and Activities, prohibits discrimination in health care programs or activities on the basis of race, color, national origin, sex, age, or disability. The Department of Human Resource Management’s Office of Health Benefits reviewed the provisions of ACA Section 1557 and implemented the processes to ensure compliance. This included:

• Publishing the Commonwealth of Virginia’s Health Benefits Program Nondiscrimination Notice on the DHRM web site by October 16, 2016.

• Ensuring language accessibility taglines are included in all significant communications.

• Working with claims administrators to ensure that all required coverage changes were effective July 1, 2017.

• Employer 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 and the mailing of 1095 forms to approximately 150,000 state and local employees in March 2017.

• 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.

• Health Benefits Plans and Programs - the Ombudsman continued to work with other DHRM employees on various components of the health plans for the state employee and retiree population, 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 for both the state and The Local Choice programs and the team worked on the benefit and claims resolutions for all plans. 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 various benefits, provisions and services.

The Ombudsman and members of her team, as requested, also assisted with the development of two new health plan options to be administered by the Department of Human Resource Management (DHRM) effective with Fiscal Years 2018 and 2019.

• Line of Duty Act (LODA) Health Plan - LODA offers various benefits to public safety workers injured in the line of duty or to their surviving spouses when they are killed in the line of duty. These benefits include health benefits for them and their family at the time at which they qualified for LODA benefits. DHRM became responsible for the administration of LODA health benefits effective July 1, 2017. The Ombudsman’s team assisted with updating and enrolling members in the system during the implementation phase to ensure members had access to their benefits on the effective date of the LODA Health Benefits Plans. The plans provide coverage to approximately 1,300 LODA beneficiaries and their dependents.

• COVA Local Option Health Plan (SB 364 Plan) - This plan, which is being developed pursuant to the 2016 Legislation SB 364, is a health plan option for schools, local governments and other political subdivisions. It will have one risk pool and therefore one set of rates. Its benefit design will be similar to state employee health plans. The Ombudsman will continue to work closely with the OHB policy team and Director on the ongoing development of the plan design and provisions.

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.