Slide 1: My Ombudsman MassHealth Health Plans
Presented By
Leslie Diaz, Director
June 14, 2022
Slide 2: Overview
•	About My Ombudsman
•	Review of Quarter 1 2022 data for One Care plans
o	Individuals assisted, inquiries, complaints
•	Questions and comments
Slide 3: About My Ombudsman
What we do, who we are
Slide 4: Our Mission
My Ombudsman is an independent program operated by the Disability Policy Consortium (DPC) through a contract with MassHealth. At My Ombudsman, we empower individuals, including their families and care givers, to exercise their rights and access the services provided by MassHealth.
Our mission is to ensure that MassHealth members understand their healthcare rights and health plan benefits so they can get the care they need.
Slide 5: Rooted in Disability Rights
•	Operated by the Disability Policy Consortium
•	Intentionally run by an independent non-profit
•	The lived experience of staff and members guides our work
•	Focused on member rights
Slide 6: What We Do
•	We offer information about MassHealth covered benefits, services, and member rights
•	We offer help accessing those covered benefits and services
•	We help members understand how to exercise their rights
•	We provide support and encourage self-advocacy
Slide 7: Who We Help
•	MassHealth members:
o	Members who get their MassHealth via Fee For Service (FFS), including members who have both Medicare and MassHealth
o	Members enrolled in any MassHealth plan:
•	One Care, SCO, or PACE plans
•	ACO and MCO health plans 
•	Primary Care Clinician (PCC) plan
•	Massachusetts Behavioral Health Partnership (MBHP)
Slide 8: Our Team
•	We have lived experience with disability
•	We are part of culturally and linguistically diverse communities, with in-house staff who provide services to members in Spanish, Portuguese, Haitian-Creole, American Sign Language
o	(We can also serve members who speak over 165 languages on-demand using a cultural interpreter line)
•	We have diverse work backgrounds (in counseling, housing, immigration, public health, research, self-advocacy, social work)
•	We are trained in cultural competence in disability rights history, intersectionality of disability and other identities, and the Deaf and Hard of Hearing community. Other trainings have included anti-racism, allyship, and resiliency, as well as de-escalation strategies and other topics that allow us to do our work more effectively.
Slide 9: Deaf Services at My Ombudsman
My Ombudsman is the only health care ombudsman program with a department exclusively focused on the needs of Deaf, Hard of Hearing, LateDeafened, and DeafBlind community members, as well as individuals with hearing loss. 

The department is led by Lori Siedman, who is DeafBlind and a native user of American Sign Language (ASL).

Note: this slide includes a photograph of Lori Siedman
Slide 10: Our Approach
•	Listening first
o	 Real people answer phones and email
o	 We offer support, ask questions, help figure out next steps
o	 Everyone's story matters
Slide 11: Working with My Ombudsman
•	Collaborative from start to finish
•	Member, Community Liaison, Ombudsman, and MassHealth (plus any care providers) work together 
•	Member is always at center of the process

Note: this slide includes an image that illustrates the interactive relationship between the Member, Ombudsman, Health Plan and Community Liaison. These entities are shown in four circles with the member in the largest circle. There are arrows in between each circle showing the direct connection between the member and the Ombudsman, and between them and the community liaison and the health plan. 
Slide 12: How We Help
For example, we:
•	Answer questions on how to access MassHealth benefits such as PCA services, DME, and other Long-Term Services and Supports
•	Help members understand decisions related to prior authorizations for their medication, dental services, or any other benefits by facilitating communication with their plan and/or provider, and help to identify options for moving forward if needed
•	 Explain how to file appeals or grievances 
•	And more
Slide 13: One Care Individuals Assisted
Quarter 4: October 1 – December 31, 2021
•	161 individuals submitted a total of 84 inquiries and 127 complaints (211 calls)
•	106 new individuals contacted us this quarter
Slide 14: One Care Individuals Assisted
Quarter 1: January 1 – March 31, 2022
•	153 individuals submitted a total of 67 inquiries and 131 complaints (198 calls)
•	116 new individuals contacted us this quarter
Slide 15: One Care Individuals Assisted
Quarter 1 2022
Date Range	# Inquiries	# Complaints	Total Calls	# Individuals	New Individuals	
Quarter 1	67	131	198	153	116	

Slide 16: One Care Health Plan Inquiries
Quarter 1 2022

Inquiry Subject​	Quarter 1- Jan to Mar 	
General Information	16	
Enrollment/Disenrollment	15	
Benefits/Access	12	
All others* (<11 inquiries each) *	24	
TOTAL INQUIRIES​	67	

*Includes inquiry subjects: Appeals/Grievance Process, Behavioral Health, care Coordination, Claim/Payment, DME, LTSS, Physician/Hospital, and Transportation
Slide 17: One Care Health Plan Complaints
Quarter 1 2022
Complaint Subject​	Quarter 1 – Jan to Mar	
LTSS	23	
Benefits/Access	21	
Care Coordination	17	
DME	15	
Claim/Payment	13	
All others (<11 complaints each)*	42	
TOTAL COMPLAINTS	131	
Slide 18: Common Complaints
•	LTSS
o	Members reported that their PCA and/or homemaker hours were reduced, or the number of approved hours did not adequately meet their needs.
o	Members reported problems with PCA/PCM staff and the quality of services provided.
•	Example
o	One member reported that while they were waiting for the plan's decision on their appeal, they felt their condition was worsening. My Ombudsman learned that the member didn’t know about their right to continue receiving their original number of PCA hours since they filed their appeal within a certain timeframe. My Ombudsman immediately escalated this issue to the contract managers and requested reinstatement of the original services as well as a new assessment. The assessment and nurse’s recommendation for reinstatement of the member’s original PCA hours were expedited and approved.
o	Another member was dissatisfied with their homemaker vendor due to their lack of communication and no-showing to appointments. My Ombudsman helped the member relay these concerns to their Long-Term Supports (LTS) Coordinator and landed on the resolution to request a different vendor (which was approved).
Slide 19: Common Complaints
•	Benefits/Access
o	Members' requests for dental services were denied (deemed beyond the scope of plan coverage or deemed medically unnecessary).
o	Member needs help with the authorization of a covered medical benefit.
o	Member needs help finding in-network providers for a covered benefit.
•	Example
o	Member's request for dental services was initially denied. After filing an appeal, the decision was reversed, and their services were approved. They were unable to get the services started due to communication issues between the provider and the plan. My Ombudsman contacted the member's care coordinator to explain the issue and they were able to connect the plan with the provider. Member was then immediately able to schedule an appointment for dental services.
o	Other members had trouble finding providers, such as an orthopedic specialist, an in-network dentist that provided sedation, or in-home massage therapy services. In situations where MYO and the member were unable to find a provider from the provider list, My Ombudsman involved the plan as necessary, and the members were able to find providers to work with.
Slide 20: Common Complaints
•	Care Coordination
o	Members reported that care managers were non-responsive or less responsive than desired.
o	Members reported that their care managers were ineffective or unable to solve their issues.
o	Member issues ranged from transition in care from inpatient to home, difficulty finding providers, to not knowing who their assigned care coordinators were, and needing help accessing DME or LTSS.
•	Example
o	A member reached out to My Ombudsman for help because they were dissatisfied with their care coordinator's assistance. The member said that they were having trouble finding an in-network dental provider, but when they relayed this to their care manager, per the member, they  were not helpful and repeatedly referred the member to a list of providers that were no longer in-network or not accepting new patients. My Ombudsman researched other options and worked with the plan to help the member locate one in-network provider in their area who could see them in a timely fashion. My Ombudsman helped the member file a grievance as well.
o	In all cases, My Ombudsman re-established lines of communication between members and their care coordinators by investigating the communication barriers or helping members request a change in care coordinator.
Slide 21: Outreach
How Members Heard About My Ombudsman*
Source	Quarter 4 2021	Quarter 1 2022	
Newsletter	0%	12%	
Community Based Organization	4%	10%	
Plan Brochures or Marketing	9%	9%	
Plan Member Services	3%	7%	
My Ombudsman Website or Internet Search	0%	6%	
Care Team Member	5%	5%	
Friend	4%	5%	
Magnet/One Care Mailing	6%	0%	
Other sources*	69%	46%	

*Including but not limited to outreach events, healthcare providers, etc. (< less than 3%)

Slide 22: Outreach Updates
•	We have been developing new partnerships with community health centers in Western MA, a statewide helpline for people seeking help with substance use, transgender healthcare advocates, and rural independent living centers, several department leads at the Massachusetts Commission for Deaf and Hard of Hearing, as well as schools and learning programs that serve the Deaf and Hard of Hearing communities. 
•	Social Media Health Equity Coalition: My Ombudsman has invited various non-profit organizations that share the mission of promoting health equity to join the My Ombudsman Health Equity Social Media Coalition (SMHEC). The goal of this group of diverse organizations is to publicly share and support each other’s resources, events, materials, etc., through their respective social media platforms and in so doing, further help each other to reach vulnerable and potentially hard to reach communities in need of support
•	My Ombudsman began using Facebook ads to promote their Facebook page and website at the end of March. Next quarter, analysis will be done to determine the effect of these ads on website traffic and program call volume, though the impact has been noticeable already. 
•	Also in March, My Ombudsman added a way for individuals or organizations to request outreach materials (such as brochures to put in an office space) via our website. The website can be accessed at: MyOmbudsman.org
Slide 23: Thank you!
Questions or comments?
Slide 24: Contact Us
My Ombudsman
MassHealth Health Plans

•	Phone: 855-781-9898
•	Videophone: 339-224-6831
•	Email: info@myombudsman.org
•	Myombudsman website

•	Nosotros hablamos Español
•	Nós Falamos Português
•	Nou pale Kreyol
•	We use ASL
•	We use an interpreter phone service for many other languages as needed