Slide 1: My Ombudsman MassHealth Health Plans
Presentation for the One Care Implementation Council 
November 10, 2020
Leslie Diaz – 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: Agenda
•	Review of Quarter 2 and Quarter 3 Data for One Care plans
o	April 1, 2020 – June 30, 2020 Inquiries and Complaints
o	July 1, 2020 – September 30, 2020 Inquiries and Complaints
•	 Complaints 
•	 Outreach data
•	 Summary
Slide 4: One Care Health Plan Inquiries 
Quarter 2 | April 1, 2020 – June 30, 2020
Note:  the following information was show in a table.
Inquiry Subject, Number of Inquiries Received
•	Care Coordination/Care Manager = 3
•	Benefits/Access = 2
•	LTSS = 2
•	Other = 2
•	Appeals/Grievance Process = 1
•	DME = 1
•	Physician/Hospital = 1
•	Transportation = 1
TOTAL = 13
Slide 5: One Care Health Plan Inquiries
Quarter 3 | July 1, 2020 – September 30, 2020
Note:  the following information was show in a table.
Inquiry Subject, Number of Inquiries Received
•	Care Coordination/Care Manager = 3
•	Physician/Hospital = 3
•	Benefits/Access = 2
•	General Information = 2
•	LTSS = 2
•	Transportation = 2
•	Other = 1
TOTAL = 15
Slide 6: One Care Health Plan Complaints Quarter 2
April 1, 2020 –June 30, 2020
Note:  the following information was show in a table.
Complaint Topic, Number of Complaints Received*
•	Benefits/Access = 17
•	LTSS = 16
•	DME = 10
•	Care Coordination/Care Manager = 8
•	Claim/Payment = 7
•	Pharmacy/Medication = 5
•	Home Health Agency = 4
•	Physician/Hospital = 4
•	Behavioral Health = 3
•	Transportation = 3
•	Enrollment/Disenrollment = 2
•	CLAS/Accessibility = 1
•	Other = 1
TOTAL = 81

*53 unique individuals reported a total of 81 complaints
Slide 7: One Care Health Plan Complaints Quarter 3
July 1, 2020 – September 30, 2020
Note:  the following information was show in a table.
Complaint Topic, Number of Complaints Received*
•	LTSS = 14
•	Physician/Hospital = 12
•	Claim/Payment = 11
•	Benefits/Access = 10
•	DME = 10
•	Pharmacy/Medication = 9
•	Care Coordination/Care Manager = 8
•	Transportation = 7
•	Enrollment/Disenrollment = 2
•	Home Health Agency = 2
•	Plan Administration = 1
TOTAL = 86

*64 unique individuals reported a total of 86 complaints
Slide 8: Examples of Complaints for More Common Topics
•	Benefits/Access – Member missed appointment because prior authorization was still pending
•	LTSS – Member reported an unexpected decrease or disruption in their PCA services or other LTSS
•	Physician/Hospital – Member had difficulty finding in-network providers
•	Claim/Payment - Member reported bills received for authorized services, had trouble getting assistance from member services or other resolution
•	DME - Member request for DME or DME repair/replacement not processed in a timely manner
Slide 9:  Reflections on the Pandemic

•	There were some complaints from members in One Care and other programs that were related to the impact of COVID19 on access to care. A few examples in One Care:
o	member’s specialist’s office closed at the peak of the pandemic, and the only practice with the same specialty that could provide in-home services was out-of-network. 
o	member’s adult day foster care also closed, so their family had to provide support at home. 
o	member experienced delays in accessing DME because the vendor suspended in-home installations.
•	My Ombudsman was able to work with the plan in each of these cases to ensure ongoing access to care, but plans may want to consider the following as the pandemic continues:
o	When possible, thinking through alternative plans with members if seeking care outside of the home were to again become unfeasible due to safety concerns
o	Options for increased flexibility and/or other support as may be appropriate for members who may need to seek out of network care in case of future office closures
Slide 10:  My Ombudsman Outreach
How Members Heard About My Ombudsman (>3% or > 4 individuals)
Note:  the following information was show in a table.
•	Quarter 2
o	Plan Customer Service	31%
o	Care Team Member	11%
o	Friend	6%
o	MassHealth CSC	4%

•	Quarter 3
o	Plan Customer Service	32%
o	Care Team Member	12%
o	Friend	8%
o	MassHealth CSC	5%
Slide 11: Member Feedback
•	"You guys were so helpful. I had been having so much trouble getting my situation fixed and you got it done within 2-3 days. I wouldn't hesitate to refer people to you guys, and I'd use your services again. You got back to me within hours of me calling you the first time. You were all so nice.  You did everything wonderfully.  You did everything perfectly.” 
•	“[My Ombudsman] is a very compassionate and very skilled person and he was a really great person to work with. I think that your team is incredibly valuable, and the staff are incredibly compassionate and good. You’ve all been very nice and when you’re dealing with health insurance it’s nice to be able to interact with human beings and not robots.” 
•	“Everything worked out and I got my services back and I'm grateful for that. I didn't know you guys existed before and I'm glad everything worked out.” 
•	“[My Ombudsman] did everything she could do and she tried to do things that might not be possible to do. It was the insurance company that was the problem. She was very helpful and I was more than happy with the help she was able to give me. I would definitely seek out her help if I needed it in future.”
Slide 12: 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 13:  Questions/Comments?