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, 2019 through June 30, 2020. 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 2020, the Ombudsman’s team handled 10,102 requests for assistance or complaints (cases) and reviewed 105 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:

Health Benefits Premium Holiday – Participants in the State Health Benefits Program were awarded a premium holiday for the month of October 2019. Working with the Department of Accounts (DOA), the Virginia Retirement System (VRS) and the health plan vendors, the guidelines and procedures to implement the $0 premium for employees, retirees and state agencies were developed. In addition, the Ombudsman’s team handled questions and concerns related to the holiday.

Prescription Drug Explanation of Benefits - In response to a budget amendment to improve transparency in pharmacy costs, the State Health Benefits Program implemented the production of explanation of benefits (EOB) for outpatient drug coverage. The EOBs, which are the first in the health care industry, are available upon request by members in the self-insured state health plans.

State Health Program and COVID-19 - With the onset of the COVID-19 pandemic, DHRM provided guidance to agencies and employees on multiple benefit and policy topics. The Office of Health Benefits provided guidance on existing policies and services based on the changes to the “normal" health care environment and the transition to telework and virtual schooling. Members in our health plans and in the flexible spending accounts were provided with additional benefits to assist them during the time of the pandemic. Health and Flexible Benefits information that included Questions and Answers about health plan services and flexible spending account (FSA) participation and claims, developed by the Office of Health Benefits, were distributed and posted to the DHRM website.

Cardinal Human Capital Management System - The Cardinal Human Capital Management (HCM) system is a new statewide administrative system that will be used to manage and administer health benefits for the Commonwealth of Virginia agencies and localities participating in The Local Choice (TLC) Health Benefits Program. Working with DHRM team members and the Cardinal project team, the Ombudsman worked to understand the functionality of the system, provide constructive feedback and address questions and concerns related to health benefits regulations and compliance.

Adult Incapacitated Dependent (AID) Review - Dependent children covered under the components of the Health Benefits Program lose eligibility at the end of the year in which they turn age 26. Dependents who are ineligible due to age are removed from coverage effective January 1 of each year. When the dependent is deemed incapacitated and meets specific eligibility criteria as outlined in the program policies, they may continue coverage as an Adult Incapacitated Dependent (AID) past the plan’s limiting age.

This review process includes two phases. There is the initial notification for the dependents who will be removed from coverage due to reaching the health plan’s limiting age. If requested by the employee, a review of the dependent’s eligibility for continued coverage under the program’s provisions for incapacitation is initiated. If approved for this continuation of coverage under the program, the dependent is placed on a cycle for periodic evaluations to ensure the eligibility is maintained.

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

• annual member communications,
• monthly EAP promotions, and
• emails, notifications and memos to the benefit administrators with policy and procedural updates.

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.