In accordance with § 38.2-5904 B 11 of the Code of Virginia (Code) and on behalf of the State Corporation Commission (Commission), the Bureau of Insurance (Bureau) submits this annual report of activities of the Office of the Managed Care Ombudsman (Office) for the period November 1, 2023, through October 31, 2024.

The Office is charged with promoting and protecting the interests of persons covered under Managed Care Health Insurance Plans (MCHIPs[*1]). To this end, during the reporting period, the Office:

• Helped consumers secure $377,136 in direct cost savings or cost avoidance by assisting them in navigating their MCHIP’s internal appeal process.

• Assisted 208 consumers with formal appeal requests to their MCHIPs.

• Responded to 362 inquiries to the Office, with just over one-third of these 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 Centers for Medicare and Medicaid Services (CMS) adopted final rules establishing specific consumer disclosures for short-term, limited-duration health insurance and hospital and other fixed indemnity policies, as well as rules clarifying the implementation of the Mental Health Parity and Addiction Equity Act. Virginia aligned coverage guidelines for colorectal cancer screenings with federal rules and will allow a carrier to revoke, change or restrict a prior authorization for prescription drugs only in specific circumstances.

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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.