RD527 - Report on the Activities of the Office of the Managed Care Ombudsman Pursuant to § 38.2-5904 of the Code of Virginia – November 30, 2018

Executive Summary:

This annual report on the activities of the State Corporation Commission’s Office of the Managed Care Ombudsman ("Staff") covers the reporting period November 1, 2017, to October 31, 2018. During this period, the Staff provided information and formal assistance to more than 572 consumers and other individuals. The Staff responded to general questions and specific problems and issues with managed care and health insurance coverage provided by managed care health insurance plans ("MCHIPs"). The Staff helped consumers understand how their managed care plan works, the importance of reading and understanding plan documents, and methods to solve problems. The Staff formally helped consumers appeal adverse benefit determinations and, when necessary, referred consumers to other sections within the State Corporation Commission Bureau of Insurance ("Bureau") for assistance or referred them to another regulatory agency when the problems involved issues outside the regulatory authority of the Bureau. In total, the Staff responded to 465 inquiries and assisted 107 consumers in filing appeals with MCHIPs, which resulted in a $336,976 cost savings or cost avoidance to consumers using the internal appeals process. In addition, the Staff participated in outreach events and continued monitoring federal and state health insurance-related legislation. Details of these and other activities are provided herein.