RD571 - Report on the Activities pf the Office of the Managed Care Ombudsman Pursuant to § 38.2-5904 of the Code of Virginia – November 30, 2020

Executive Summary:

This annual report on the activities of the State Corporation Commission’s Office of the Managed Care Ombudsman (Office) covers the reporting period November 1, 2019, to October 31, 2020. During this period, the Office provided information and formal assistance to 645 consumers and other individuals covered by managed care health insurance plans (MCHIPs). The Office helped consumers with MCHIPs:

• Understand how their benefit plans work;

• Realize the importance of reading and understanding plan documents;

• Use tools to solve problems; and

• Appeal adverse determinations.

When necessary, the Office referred consumers to other sections within the State Corporation Commission Bureau of Insurance or to other regulatory agencies for assistance.

In total, the Office responded to 464 inquiries and assisted 181 consumers in filing appeals with MCHIPs, resulting in a $318,296 cost savings or cost avoidance to consumers using the internal appeals process. In addition, the Office continued monitoring federal and state health insurance-related legislation. Details of these and other activities are provided in this report.