This annual report on the activities of the Ombudsman for the Office of Health Benefits (OHB) covers the period from July 1, 2023 through June 30, 2024. 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 2024, the Ombudsman’s team handled 8,187 requests for assistance or complaints (cases) and reviewed 198 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:

CRM Migration Project – The Office of Health Benefits is currently using an on-premises Dynamics CRM (Customer Relationship Management) system to track incoming inquiries and requests. The Department of Human Resource Management (DHRM) Information Technology team proposed a plan to migrate the existing Dynamics CRM system (on-premises) to the cloud solution, Dynamics 365, to capitalize on enhanced security, and reliability of cloud computing. The cloud reduces maintenance and system updates typically associated with on-premises upkeep.

As a part of this project, the Ombudsman and Systems Associate Director were assigned as OHB Project Managers and CRM Application Owners. They work with the DHRM IT Project Owners to coordinate activities and ensure all work is performed and meet the department’s expectations and to ensure the security standards of the Commonwealth of Virginia are upheld. This is an ongoing project with expected migration to the cloud in Fiscal Year 2025.

Special Enrollment for Adult Incapacitated Dependents – Section 2.2-2818 of the Code of Virginia revised the adult incapacitated dependent (AID) requirements for continuation of coverage due to a physical or behavioral health condition under the State Employee and Retiree Health Benefits Programs. Effective July 1, 2023, the residency requirement for AID was expanded to allow eligible dependents to be receiving residential support services. This allows the AID to reside in a group home, nursing home/convalescent home, long-term care facility or similar facility that provides services for physically and/or mentally disabled patients.

To comply with the new AID criteria, and in compliance with the program provisions, our office provided a special enrollment period to allow employees and retirees to cover their eligible over-age 26 dependents if they met the program’s eligibility requirements including the new expanded residency criteria, and the health plan’s medical criteria. The special enrollment period ran from July 1 through August 29, 2023. The Ombudsman and members of her team responded to inquiries about the new criteria, provided guidance on the review process and reviewed the requests received during the special enrollment period. While there were numerous inquiries related to the notification, less than 50 applications were submitted for review. Of the requests received for review, only three dependents met the new requirements and were reenrolled into the health plan coverage.

Cardinal Benefit Event Entry Tool –The Benefit Event Detail page was designed to simplify the benefit event processing in Cardinal HCM. The new tool (page) captures all the life event detail (e.g., event date, paperwork receipt date, current and future coverage level, type of benefit change), calculates the benefit event effective dates, and automatically selects the benefit event class needed for the system update. This tool minimizes errors in the processing of election requests submitted outside of the annual enrollment period.

This project was initiated in response to the trends and issues identified by the requests submitted to OHB and Cardinal Post Production Support (PPS). The initial launching was announced in a Cardinal Forum in July 2023. The Ombudsman and members of her team, along with the OHB Associate Director for Systems, worked with the Cardinal PPS team on the Program’s guidelines for the qualified mid-plan year life events (QMEs) and the allowable election changes for each event under the health care and flexible spending accounts. While the initial work on this project began in the prior fiscal year, this ongoing project requires regular meetings with the Cardinal PPS team, the Ombudsman and various members of the OHB team. The team continues to review and make necessary programming changes to ensure this tool is a reliable resource for the agencies and ensure program compliance.

Redesign of Open Enrollment Communications –The OHB team worked on the literature for the annual Open Enrollment period. The communication materials provide information on the changes for the new plan year, instructions on making an Open Enrollment election request and addresses program administration and policy guidance identified by monitoring the OHB inquiry trends.

This year’s Open Enrollment (OE) brought a new design to the annual Spotlight on Your Benefits newsletter and the Open Enrollment page on the DHRM website. Spearheaded by the OE coordinator and the Associate Director of Policy, the redesign and implementation project included the Ombudsman, members of her team, the DHRM webmaster and communications manager. The newsletter’s new look and layout, along with the redesign of the Open Enrollment webpage, received extremely positive feedback from the agencies’ benefits administrators and our members.