RD716 - Annual Report on Ombudsman Activities and Services for the Office of State and Local Health Benefits Programs – Fiscal Year 2023 – December 1, 2023

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, 2021 through June 30, 2022. 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 2022, the Ombudsman’s team handled 11,377 requests for assistance or complaints (cases) and reviewed 140 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:

Request for Proposals (RFPs) for IRO - The Ombudsman and members of her team worked with the DHRM contracts team on the development and review of the RFPs to secure the services of Independent Review Organizations (IRO) needed for the OHB external appeal process.

Cardinal Migration for the Health Benefits Program - With the migration of health benefits and flexible spending accounts into the Cardinal system, the Ombudsman and other members of the OHB team worked closely with Cardinal personnel, attending training sessions, participating in forums and reviewing current and future business processes. Serving as a subject matter expert (SME), the Ombudsman assisted in providing expertise to the project team on the OHB policies for specific topics related to the benefits administered by the Office of Health Benefits. OHB assumed the administration of the Extended Coverage/COBRA process for the agencies that transitioned to Cardinal during the fiscal year. The team also established interim processes for the transfer of employee records between the legacy system and Cardinal HMC and handled the initial enrollment requests for the retirees group participants with benefits through the Virginia Retirement System (VRS).

Open Enrollment - The Ombudsman, her team and the Policy team worked closely with the DHRM Communications Manager and each of the plan vendors to develop material for the 2022 Open Enrollment period. With the transition of many state agencies to Cardinal HCM, the team developed open enrollment material specific to the Cardinal population, in addition to the normal material. The team also worked with the vendors to obtain Spanish versions of many of the documents and forms.

Health Benefits Communication Campaigns - The team wanted to increase the utilization of the wellness and preventive services offered by the health plans. The Office of Health Benefits, working with the health plan vendors, developed communications that focused on specific relevant topics, including information on the importance of taking ownership of their health and providing helpful tools, vendor apps and web site information to assist them in the process.

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 Local Health Benefits Programs.