RD490 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2018

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, 2017 through June 30, 2018. 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 2018, the Ombudsman’s team handled 9,217 issues and reviewed 152 formal appeal requests. 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:

Health Benefits Plans and Programs - working with members of the OHB Policy Team and the Communication Manager, the Ombudsman assisted in the development of

• annual member communications
• member handbooks and handbook amendments for the health plans,
• monthly EAP promotions, and
• a revised Getting to Know Your Benefits brochure for newly eligible state employees.

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

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 for the 2017 tax year to approximately 150,000 state and local employees.

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 for the annual open enrollment period and as a newly eligible employee.

The Ombudsman worked with other DHRM employees on various components of the program for the state employee and retiree population, including the related communication materials.

The additional components include:

• The comprehensive health and wellness management program, MyActiveHealth
• The premium rewards program,
• Capital Square Healthcare Clinic and
• ALEX, the health benefits program online counseling tool.

Our team continues to work with the health plan vendors to develop a communication strategy aimed at educating both the members and the provider community regarding various benefits, provisions and services available through the state health benefits program.