RD764 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs – Fiscal Year 2021 – December 1, 2021

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, 2020 through June 30, 2021. 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 2021, the Ombudsman’s team handled 10,190 requests for assistance or complaints (cases) and reviewed 169 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 - The Office of Health Benefits provided a premium holiday for the month of December for those enrolled in the State Health Benefits Program. The premium holiday applied to most state employees and retiree group participants (which include retirees, survivors, LTD participants) and Extended Coverage/COBRA participants.

Annual Flu Shot Program - Under the health plans, members were able to get a free flu shot at physicians’ offices or pharmacies participating in their health plan’s network. Member communications and web site documents for the 2020-2021 flu season were developed and distributed in the fall of 2020. We also worked with the Capitol Square Healthcare Clinic to coordinate two Drive-Thru Flu Shot events during October 2020.

Premium Reward Program Engagement - In an effort to increase awareness and engagement in the Premium Reward program, the Office of Health Benefits sent email communications to all employees actively enrolled in COVA Care and COVA HealthAware that included directions on how to update and submit a health assessment. The mass emails was issued on 9/16/2020. There were 2,027 health assessments completed by eligible members from 9/16 - 9/30/2020.

Request for Proposals (RFPs) for Medicare-Coordinating Health Plans - The Ombudsman and members of her team worked with the OHB policy team, our consultants, and the DHRM contracts team on the development and review of the RFPs for the two components of the health plans for our Medicare-eligible retiree population. This project is ongoing.

Open Enrollment Webinars for Benefits Administrator -In addition to the annual communication campaign for Open Enrollment, the Office of Health Benefits held two webinars for agency benefits administrators and managers in late April. These sessions modified the normal practice of vendor participation at agency Open Enrollment meetings and health fairs. The webinars included an Open Enrollment presentation with the health plan vendors and OHB available to answer questions. Employees submitted over 22,000 transaction for the Open Enrollment period with approximately 600 requests to OHB for assistance.

Getting to Know Your Benefits Brochure - This brochure provides an overview of the State Employee Health and Flexible Benefits. It was initially established to provide general information for new state employees but it was determined that the brochure would be a resource for all state employees. The Ombudsman and her team worked to update the information and expand the content to include new programs such as Shared Savings and Premium Rewards. The new brochure also provides general information on federally required notices and mandates that apply to our programs and it is now available to all prospective and current employees on the DHRM website.

• Cardinal Migration for Health Benefits Program – In preparation for the migration of information and data into the Cardinal system, the Ombudsman and other members of the OHB management team participated in meetings with Cardinal personnel to review current and future business processes. Serving as a subject matter expert (SME), the Ombudsman assisted in providing critical expertise to the project team, participating in the Cardinal Business Process Workshops and meetings on specific topics related to the benefits administered by the Office of Health Benefits.

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.