RD638 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs - Fiscal Year 2019

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, 2018 through June 30, 2019. 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 2019, the Ombudsman’s team handled 8,783 issues and reviewed 138 formal appeal requests. In an effort to maximize the accessibility and effectiveness of the Health Benefits Program, the team continues to:

• resolve issues and solve problems in a timely manner;

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

• update policies and provide meaningful communication to our customers.

Key initiatives and projects managed during the fiscal year include:

Procurement of Health Benefits Plan Administrators – the Ombudsman worked extensively with other DHRM employees to procure services for the administration of the statewide Commonwealth of Virginia employee health benefits program, The Local Choice (TLC) health benefits program, and the Line of Duty Act (LODA) health benefits plans, as well as fullyinsured regional plans for the state employee and TLC programs. The TLC program is an optional health benefits program administered by OHB for political subdivisions of the Commonwealth. The LODA Health Benefits Plans cover eligible public safety employees/volunteers permanently injured or killed in the line of duty and/or their eligible family members.

Shared Savings Incentive Program - The Office of Health Benefits implemented a shared savings incentive program designed to create savings by rewarding members who choose to receive treatment at facilities that offer quality care at a lower cost. The program, SmartShopper, provides opportunities for participants in the COVA Care and COVA HDHP Plans to shop for certain medical services. If better-value facilities are chosen through the shopping process, the enrollee will receive a cash incentive. Registration with the administrator is required in order to shop. Participation in the program is strictly voluntary.

The program has particular promise for COVA Care, the state’s copay-based plan which is the most popular plan among state employees. Copay-based health plans typically provide little incentive for members to shop for lower prices; this program will address that issue.

Communication - working with members of the OHB Policy Team and the DHRM Communication Manager, the Ombudsman assisted in the development of:

• annual member communications,

• updated COVA HDHP member handbook and handbook amendments,

• monthly EAP promotions, and

• emails, notifications and memos to the benefit administrators with policy and procedural updates.

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.

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 and benefit available when they have an opportunity to enroll in health coverage.

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 and TLC health benefits programs.