Profile of the Minnesota Office of the Ombudsman for Managed Health Care

November 2002

Established in 1985, the Minnesota Office of the Ombudsman for Managed Health Care is one of the oldest health assistance programs in the nation. The Ombudsman acts as an advocate for Medicaid consumers in prepaid health plans and for consumers in a state-funded managed care program for low-income citizens. The program's location within the Department of Human Services gives it access to information regarding Medicaid eligibility and managed care enrollment. To minimize conflicts of interest, the office reports to the Assistant Director of Purchasing and Service Delivery, who has responsibility for fee-for-service Medicaid.

Statewide, the office has four ombudsmen, one individual providing support, and one person handling the database. The four state ombudsmen work with 80 local-level advocates, who are mostly county employees. The local advocates come together for skills-building conferences three times a year, and they also receive regular telephone support from the State Ombudsman. The number of Minnesota residents in public prepaid health plans (and potentially eligible for services of the Ombudsman) is 420,000.

The phone number for the Ombudsman is published in managed care member handbooks, rights and responsibilities brochures, enrollment notices, and denial notices. The Ombudsman Office has an interagency agreement with the Department of Health, which licenses and regulates plans, to investigate quality-of-care issues. The Ombudsman Office works on access, service, and billing issues, first working to resolve the cases informally but then, if needed, helping consumers write complaints, gathering data, and representing consumers in grievances and hearings.

To analyze systemic issues, besides looking at statistics of consumers calling the Ombudsman and local advocates, the Ombudsman receives and analyzes all notices of denial, reduction, and termination for managed care enrollees. This data is kept in an Access database. Cases handled by the Ombudsman program are tracked through a web-based system.

In 2001, the program received 6,500 calls. Of these, 2,500 became actual cases, while the others required only information and referral. Of those 2,500 cases, 167 became formal state-level appeals. Although the program has no statutory authority over fee-for-service cases, about 5 percent of the callers are on Medicaid fee-for-service, and the program provides some help to these callers in information-gathering and negotiating. This fall, the Ombudsman's scope was expanded to include oversight of the information and referral helpdesk for fee-for-service consumers. One of the top systemic issues for Minnesota Medicaid beneficiaries is access to dentists and dental services such as orthodontia, accounting for over one-third of the calls in 2001.