The 1999 Virginia General Assembly enacted, and Governor
Gilmore signed legislation creating §38.2-5904 of the Code of
Virginia. This legislation, which became law on July 1, 1999,
established a new office within the Bureau of Insurance: the
Office of the Managed Care Ombudsman.
What does the Ombudsman do?
The principal function of the Managed Care Ombudsman is to
help Virginia consumers who have health care insurance provided
by a Managed Care Health Insurance Plan (MCHIP), such as a Health
Maintenance Organization or Preferred Provider Organization.
The Managed Care Ombudsman will promote and protect the interests
of covered persons under MCHIPs in the Commonwealth. The Managed
Care Ombudsman can assist consumers in understanding and exercising
their rights of appeal of adverse decisions made by MCHIPs.
In addition, the Managed Care Ombudsman will also conduct consumer
outreach efforts so that more Virginians are aware of the Bureau
of Insurance, and how the Ombudsman can provide assistance.
A major responsibility of the office involves educating consumers
about their rights and how to advocate on their own behalf when
they have a problem or concern about a MCHIP. The Ombudsman
will collect information from MCHIPs regarding complaint, grievance
and appeal procedures, and upon request, use this information
to answer questions and assist covered individuals. The Ombudsman
will also answer questions regarding managed care, assist individuals
in understanding how managed care functions and provide information
on the types of MCHIPs available in Virginia. Experienced staff
in the Ombudsman's office will be able to explain to individuals
various regulatory requirements that MCHIPs must comply with
and respond to questions about laws relating to MCHIPs. Information
will be provided to covered persons and other citizens concerning
MCHIPs and utilization review organizations.
When a problem occurs, know your rights!
There are special laws governing the activities of MCHIPs that
are designed to protect consumers.
The Managed Care Ombudsman can answer inquiries about
MCHIPs and managed care, and help individuals who experience
problems. This includes assisting individuals who desire to
appeal an adverse decision made by a MCHIP.The Ombudsman can
answer questions about regulatory requirements affecting MCHIPs,
including mandatory benefits. Speakers will be available to
interested groups to discuss managed care and MCHIPs, and as
it is developed, written information describing different types
of MCHIPs and managed care will also be available.
The Managed Care Ombudsman cannot investigate or resolve
complaints, but can refer individuals who have a complaint to
the internal review mechanisms at the MCHIP or to the appropriate
government agency.
If you would like the Office of the Managed Care Ombudsman
to assist you with your appeal, you are required to complete
and sign the Ombudsman's Inquiry Form. The information and signature
that you provide will authorize us to contact your managed care
health insurance plan about your appeal. You may download
the form, call the Office of the Managed Care Ombudsman
to request a form or you may request a form via electronic mail.
(Please be sure to provide your full name and mailing address.)
If you have questions or if you need any other information,
please contact the Office of the Managed Care Ombudsman through
the means most convenient for you. |
times since July 1, 2007
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