Slide 1: My Ombudsman – MassHealth Health Plans
Presentation for the One Care Implementation Council 
February 9, 2021
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 4 data for One Care plans
o	October 1, 2020 – December 31, 2020 Inquiries and Complaints
•	 Examples of common complaints
•	 Outreach data
Slide 4: One Care Health Plan Inquiries 
Quarter 4 | October 1, 2020 – December 31, 2020
Inquiry Subject	Number of Inquiries Received	
Pharmacy/Medication	5	
General Information	2	
Transportation	2	
Physician/Hospital	1	
Benefits/Access	1	
LTSS	1	
DME	1	
TOTAL INQUIRIES	13	

Slide 5: One Care Health Plan Complaints
Quarter 4 | October 1, 2020 – December 31, 2020
Complaint Subject	Number of Complaints Received	
Benefits/Access	16	
Care Coordination/Care Manager	15	
LTSS	12	
Physician/Hospital	9	
Claim/Payment	9	
DME	8	
Various other subjects	4 or fewer	
TOTAL	89	

Slide 6: One Care Individuals Assisted
Quarter 4 | October 1, 2020 – December 31, 2020
Quarter 4
•	9 individuals submitted 13 inquiries
•	66 individuals reported a total of 89 complaints
Calendar Year 2020
•	231 individuals submitted a total of 466 inquiries and complaints
Slide 7: Examples of Complaints for Most Common Topics (1 of 3)
•	Benefits/Access - 16 total complaints
o	My Ombudsman received 9 complaints related to dental care. In 7 of these cases, members reported denials of implants, bridges, braces, and other types of dental work. They all needed help understanding the process for contesting the decisions made. 
o	In these dental cases, My Ombudsman educated members on the appeals process and helped facilitate support from their providers. In a few cases, the denials were overturned or partially approved; in others, the members had to continue the appeals process at the Board of Hearings.
Slide 8: Examples of Complaints for Most Common Topics (2 of 3)
•	Care Coordination - 15 total complaints
o	In 6 of these cases, members reported communication delays or lack of follow-up from their care managers. In 7 cases, members reported that their care managers could not provide them the proper level of support for their needs, so they requested new care coordinators.
o	My Ombudsman identified the source of some delays in communication as telephone issues or scheduling miscommunications. In other situations, My Ombudsman helped facilitate the members' requests for new care managers.
Slide 9: Examples of Complaints for Most Common Topics (3 of 3)
•	LTSS - 12 complaints
o	My Ombudsman received 5 complaints from members who reported a decrease in their approved PCA hours and needed help appealing the decision.
o	In these cases, My Ombudsman helped members request reassessments or obtain additional support from their providers, which resulted in increased hours or provision of additional supports. In some cases, members had to pursue the next level of appeals at the Board of Hearings, but the plans authorized extension of their services until new decisions were made.
Slide 10: Complaints Related to the COVID-19 Pandemic
•	My Ombudsman received some complaints related to the impact of COVID-19 on access to care. In the examples below, immediate communication between members, care teams, and the plans played a crucial role in finding quick resolutions:
o	A member had difficulty finding PCAs due to their limited availability (as a result of the pandemic), so the plan offered homemaker and companion services until PCAs could be found.
o	One vendor's masks supply was backordered, so the member (high-risk, living in a group home) was provided with the plan's own emergency supply usually reserved for staff.
Slide 11: My Ombudsman Outreach
How Members Heard About My Ombudsman (>3% or > 4 individuals)

Quarter 4
Plan Customer Service	25%
Care Team Member	6%
MassHealth CSC	4%
Slide 12: Member Feedback
•	“I really appreciate that [My Ombudsman is] here to provide services when needed.”

•	“I was calling because I couldn’t get [a] nurse case manager. After [My Ombudsman] entered the scene, my nurse case manager was [assigned] on the spot.”

•	“[My Ombudsman] was very helpful. He helped me get everything fixed. I've also referred you to other people and you really helped them get the results they needed too.”
Slide 13: Contact My Ombudsman
We speak Spanish, Portuguese, Haitian-Creole, Cantonese and we use ASL.

Office Hours: Monday – Friday, 9am-4pm
Call Center: (855) 781-9898
Videophone: (339) 224-6831
Email: info@myombudsman.org 
My Ombudsman Website

Slide 14: Questions/Comments?