RD737 - Report on the Activities pf the Office of the Managed Care Ombudsman Pursuant to § 38.2-5904 of the Code of Virginia – December 1, 2021

Executive Summary:

This annual report on the activities of the State Corporation Commission ("SCC")’s Office of the Managed Care Ombudsman ("Office") covers the reporting period November 1, 2020 to October 31, 2021. During this period, the Office provided information and formal assistance to 633 consumers and other individuals covered by managed care health insurance plans ("MCHIPs"). The Office helped consumers with MCHIPs in the following ways:

• 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 SCC’s Bureau of Insurance ("Bureau") or to other regulatory agencies for assistance.

In total, the Office responded to 467 inquiries and assisted 166 consumers in filing appeals with MCHIPs, resulting in a $519,725.00 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.