A key beneficiary protection, particularly for LTSS services, is the availability of an independent, conflict-free entity to serve as an ombudsman for participants. The ombudsman would provide individuals with free assistance in accessing their care, understanding and exercising their rights and responsibilities, and in appealing adverse decisions made by their plan. Through this individual assistance the ombudsman can also identify systemic problems and work with state and plan officials to raise and resolve issues. Although the ombudsman can address any issues that arise for MCO members, it is anticipated that most issues would involve LTSS and the ombudsman should have particular LTSS expertise.

  • The ombudsman must be able to provide advice, information, referral and direct assistance in dealing with the MCOs, providers and the state agency. The ombudsman must provide individuals with assistance navigating the program, including:
    • Understanding benefits, coverage or access rules and procedures, and participant rights and responsibilities;
    • Making enrollment decisions;
    • Exercising rights and responsibilities, including Olmstead rights around community integration;
    • Accessing covered benefits;
    • Resolving billing problems;
    • Appealing MCO denial, reduction or termination of service decisions;
    • Raising and resolving quality of care and quality of life issues;
    • Ensuring the right to privacy, consumer direction, and decision-making; and
    • Understanding and enforcing an individual’s civil rights
  • The ombudsman should be accessible to all individuals through telephonic helplines and, where appropriate, in-person appointments.
  • MCOs must be required to notify individuals of the availability of the ombudsman in enrollment and other marketing materials including annual notices summarizing grievance and appeal procedures, and all notices of denial, reduction or termination of a service, whether sent in writing or in another alternative format.
  • The ombudsman must be permitted to participate in participant advisory committee meetings with MCOs and state officials. The ombudsman should prepare reports to the state, at least annually. These reports should be made public.
  • The ombudsman must have established channels of access to senior officials at the MCO and the state.  A schedule of periodic meetings between the ombudsman and plans and the ombudsman and the state must be established to discuss patterns and systemic issues.
  • The ombudsman must be funded by the state.  Funding must be sufficient to carry out these services.
  • The ombudsman must have expertise in the on-the-ground delivery of LTSS.  If the plan is integrating Medicaid and Medicare benefits, experience with the Medicare program is also necessary.
  • The ombudsman should be housed in an independent organization with an established record of beneficiary representation.  The organization must have credibility with the senior and disability communities and the capacity to foster formal links with both communities.
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