Slide 1: My Ombudsman MassHealth Health Plans
Presentation for the One Care Implementation Council 
September 8, 2020
Leslie Diaz – Acting Director
Slide 2: My Ombudsman’s Mission
My Ombudsman is operated by an independent non-profit program (the Disability Policy Consortium). At My Ombudsman, we strive to empower individuals, including their families and caregivers, to exercise their rights and access the services provided by MassHealth and its managed care plans.
We ensure that individuals can exercise their rights and access the benefits they have as a MassHealth member. 
Slide 3: My Ombudsman Staff
Our combined experiences are a major strength of our team and allow us to approach members with understanding, respect and expertise in a variety of areas.
We are
•	 People who have lived experience with disability
•	 Members of culturally and linguistically diverse communities
•	 Experienced in counseling, criminal justice, housing, immigrants’ rights, public health, self-advocacy, academic research, and social services
•	 Always learning

Slide 4: My Ombudsman’s Approach
A Community Liaison
•	 Listens first
•	 Asks questions
•	 Researches and informs, makes a referral, or opens a complaint
An Ombudsman 
•	 Is assigned to the complaint
•	 Contacts the member within 1 business day of the assignment
•	 Begins investigation right away

Slide 5: My Ombudsman’s Approach
•	As a neutral third party independent of the plan, we do not have internal knowledge of member information
•	Our role is to mediate, investigate, and to provide information that empowers members to self-advocate
•	We communicate regularly with the member, providers, care team, and the plan

Slide 6: Scenario 1 – Intake
•	Ann attempts to find out if a tablet that will be used for tele-health, prescription management and addressing isolation is covered by her One Care plan. 
•	Over a period of many months, her care manager fails to return phone calls and/or provide answers to her questions. Ann's former care manager was reassigned months ago, but Ann was not informed of the change. She does not know who her care manager is, or how to find out.   
•	She asked a family member to help her with an online search to get answers about what is covered but could not locate that information. Ann’s family member calls My Ombudsman to ask for help.

Slide 7: Scenario 1 – Intake

•	Ann attempts to find out if a tablet that will be used for tele-health, prescription management and addressing isolation is covered by her One Care plan. 
•	Over a period of many months, her care manager fails to return phone calls and/or provide answers to her questions. Ann's former care manager was reassigned months ago, but Ann was not informed of the change. She does not know who her care manager is, or how to find out.   
•	She asked a family member to help her with an online search to get answers about what is covered but could not locate that information. Ann’s family member calls My Ombudsman to ask for help.
Slide 8: Scenario 1 – Mediation & Resolution
Initial steps - identify issues and potential solutions together
•	 Gather information about the member’s needs around telehealth, prescription management, and social isolation
•	What types of services are you seeking through telehealth? 
•	In what ways would the tablet benefit you for Prescription management? Social isolation?
•	 Help the member access care coordination
•	Contact member services with the member and find out who their new care manager is
•	Set up time to talk with care manager and member, or just care manager (if member agrees) to discuss unaddressed needs

Slide 9: Scenario 1 – Mediation & Resolution

Intermediate steps – follow up with member and plan to
•	 Ensure member now has open communication with care manager
•	 Confirm that care manager has placed the request for a tablet and other tools/supports identified in the earlier conversation
•	 Encourage member to gather documentation from providers regarding need for tablet and other services

Slide 10: Scenario 1 – Mediation & Resolution
Final steps – remind or inform the member of their rights to
•	 File an appeal if their DME request is denied
•	 File a grievance if they wish to express their dissatisfaction with the initial care coordination issues
•	 Contact My Ombudsman for additional support with all the above and for help finding additional resources

Slide 11: Scenario 2 – Intake
•	Bob is told on Wednesday that he’ll be released from the hospital on Friday.
•	The hospital discharge planners are denying his request for increased home care services and plan to move him to a temporary care facility.
•	Bob knows he has a right to choose home care and the idea of going into a care facility is negatively impacting his mental health.
•	He does not understand why his care plan is not assisting him with the discharge planning process. 
•	On Thursday, he reaches out to his care manager, but she is on vacation. It is now Friday morning. Bob needs a rapid response from his care plan but has not heard back from the on-call care manager. 
•	Bob calls My Ombudsman to avoid discharge into a care facility. 

Slide 12: Scenario 2 - Intake
•	Bob is told on Wednesday that he’ll be released from the hospital on Friday.
•	The hospital discharge planners are denying his request for increased home care services and plan to move him to a temporary care facility.
•	Bob knows he has a right to choose home care and the idea of going into a care facility is negatively impacting his mental health.
•	He does not understand why his care plan is not assisting him with the discharge planning process. 
•	On Thursday, he reaches out to his care manager, but she is on vacation. It is now Friday morning. Bob needs a rapid response from his care plan but has not heard back from the on-call care manager. 
•	Bob calls My Ombudsman to avoid discharge into a care facility. 

Slide 13: Scenario 2 – Mediation & Resolution
Initial Steps
•	Contact member and gather information right away
•	Check on member’s well-being, ask about behavioral health supports
•	Gain understanding of care plan’s and care manager’s involvement up to now
•	Escalate the case to the plan’s leadership team
•	Convey that member does not want to go to a rehab facility, and is instead seeking more home-care hours/additional supports so that he can be discharged to his home
•	Expect that the plan will contact member and get back to us right away with updated information and next steps
•	 Contact hospital discharge planners
•	Clarify and confirm member’s understanding of discharge plan and reasons why he’s not being discharged back into the community 
•	Ask what member needs to re-enter community safely
Slide 14: Scenario 2 – Mediation & Resolution
Final Steps 
•	 Support member until discharge plan is in place
•	 After emergent issue has settled, ask member if they think they would benefit from an LTS-C
•	 Inform member of their right to file a grievance or appeal (if in home services are denied)
Slide 15: Summary
My Ombudsman
•	 Listens with understanding and respect
•	 Looks at the whole person, not just their surface complaint
•	 Identifies solutions and offers them as choices to the member
•	 Serves as a bridge between the member and their plan
•	 Empowers members to access their benefits and exercise their rights

Slide 16: Contact My Ombudsman
We speak Spanish, Portuguese, Cantonese and we use ASL.

Office Hours	Monday – Friday, 9am-4pm
Call Center	(855) 781-9898
Videophone	(339) 224-6831
Email	info@myombudsman.org 
Website 	www.myombudsman.org
Slide 17: Questions/Comments?