On behalf of the State Corporation Commission, the Bureau of Insurance (Bureau) submits this annual report on the activities of the Office of the Managed Care Ombudsman (Office) pursuant to § 38.2-5904 B 11 of the Code of Virginia to the standing committees of the Virginia General Assembly having jurisdiction over insurance and health, and to the Joint Commission on Health Care. This report covers the period November 1, 2021, to October 31, 2022.

The Office is responsible for promoting and protecting the interests of covered persons under managed care health insurance plans (MCHIPs)(*1) In this reporting period, the Office responded to 416 inquiries and assisted 172 consumers in filing appeals with MCHIPs, resulting in a $105,780 cost savings or cost avoidance to consumers using the internal appeal process.

The Office also helped consumers enrolled in MCHIPs understand how their benefit plans work; realize the importance of reading and understanding plan documents; understand the documentation to use in an appeal; and appeal adverse determinations. When necessary, the Office referred consumers to other sections within the Bureau or to other state and federal regulatory agencies for assistance.
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(*1) A Managed Care Health Insurance Plan or "MCHIP" is an arrangement for the delivery of health care in which a health carrier agrees to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis. The most common examples of MCHIPs are Health Maintenance Organizations or Preferred Provider Organizations.