RD683 - Report on the Activities of the Office of the Managed Care Ombudsman – December 1, 2023

Executive Summary:

On behalf of the State Corporation Commission (Commission), the Bureau of Insurance (Bureau) submits this annual report on the activities of the Office of the Managed Care Ombudsman (Office) in accordance with § 38.2-5904 B 11 of the Code of Virginia (Code) for the period November 1, 2022, through October 31, 2023.

The Office is charged with promoting and protecting the interests of persons covered under managed care health insurance plans (MCHIPs(*1)). To this end, the Office reported the following results:

• Through its assistance with the internal appeal process, helping consumers secure $409,800 in direct cost savings or cost avoidance–a 287% increase over the $105,780 secured in the previous reporting period;

• Helping 215 consumers with formal appeal requests, a 25% increase over the previous reporting period; and

• Assisting with 423 consumer inquiries, a slight increase over the prior reporting period, with nearly one-third of these inquiries being referred to other entities.

In addition, the Office is responsible for reporting on new developments in federal and state health insurance laws. At the federal level, the end of the Covid-19 public health emergency on May 11, 2022, drove many of the changes in health insurance policy, while significant developments in Virginia included revisions to the specifications for the essential health benefits benchmark plan and requirements related to electronic prior authorization and real-time benefit tools for prescription drugs that will both take effect in 2025.
(*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.