In accordance with subsection B 11 of § 38.2-5904 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) from November 1, 2024, through October 31, 2025.

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 $386,798 in direct cost savings or cost avoidance by assisting them in navigating their MCHIP’s internal appeal process;

• Assisted 207 consumers with formal appeal requests to their MCHIPs; and,

• Responded to 383 inquiries, with 45 percent of these being referred to other entities outside of the Bureau.

As part of its annual report, the Office is also required to include a summary of significant new developments in federal and state health insurance laws. At the federal level:

• Enhanced premium tax credits, created under the American Rescue Plan Act of 2021(*2) to help qualified individuals purchase qualified health plans during the COVID public health emergency, are set to expire at year-end absent congressional legislation to extend them.

• The Centers for Medicare and Medicaid Services (CMS) issued its annual “Notice of Benefit and Payment Parameters" rules for the Health Insurance Marketplace. It followed these with the release of the “Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability Final Rule." However, just prior to its August 25th effective date, key provisions of the marketplace integrity and affordability final rule were stayed by a federal court.

In the Commonwealth, the Virginia General Assembly enacted various provisions related to prior authorization for health care services, while also adding coverage requirements for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS). It also required insurers to provide coverage for mental health and substance use disorder benefits for children, adolescents, and adults, and apply the definitions of “generally accepted standards of mental health or substance use disorder care" and “medically necessary," as provided in the bill for any determination of medical necessity, prior authorization, or utilization review under such coverage.
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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.
(*2) H.R. 1319, 117th Cong. (2021).