RD599 - Report on the Activities of the Office of the Managed Care Ombudsman Pursuant to § 38.2-5904 of the Code of Virginia

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, 2018, to October 31, 2019. During this period, the Staff provided information and formal assistance to more than 584 consumers and other individuals. The Staff responded to both general questions and specific problems with information about benefit coverage provided by managed care health insurance plans ("MCHIPs"). The Staff helped consumers:

• Understand how their benefit plans work

• Emphasized the importance of reading and understanding plan documents

• Offered tools to solve problems

• Helped consumers appeal adverse benefit determinations, and

• When necessary, referred consumers to other sections within the State Corporation

Commission Bureau of Insurance or to other regulatory agencies for assistance.

In total, the Staff responded to 445 inquiries and assisted 139 consumers in filing appeals with MCHIPs, resulting in a $278,055 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 in this report.