Quality in Managed Long-Term Services and Supports Programs. D. Ombudsman


Technically an ombudsman is a neutral party that can advocate for the member in disputes with the MCO or state regarding their services and supports. Three of the examined programs offered independent state ombudsman programs either devoted exclusively to the MLTSS program (Wisconsin) or to Medicaid managed care more generally (Texas, Minnesota).

Four programs (Michigan, Tennessee, Texas, and Wisconsin) also require that the MCO offer ombudsman-like services to their members, but these services are clearly not independent as these services are provided by MCO staff. The MCOs refer to these positions as variably as "member advocates", "member rights specialists" or "customer services".

In addition to advocacy, responsibilities for both the independent ombudsmen and those fulfilling ombudsman-like roles in the MCOs assume similar additional functions. These additional tasks include member/family education about the availability of services and how to access services and the complaints/appeals process. Both may also have duties related to tracking grievances and making recommendations for improvement to the provision of care. Exhibit 7 summarizes the ombudsman functions assumed by the state and MCOs in each program.

EXHIBIT 7. MCO Ombudsman Function and State Ombudsman Programs
    AZ     MI     MN     NC     PA     TN     TX     WI  
MLTSS/Medicaid State Ombudsman Program
   Education     X       X X
   Advocacy/Assistance     X       X X
   Tracking/Quality Improvement       X       X X
MCO Ombudsman Functions
   Education   X       X X X
   Advocacy/Assistance   X   X1   X X X
   Tracking/Quality Improvement   X       X X  
  1. Through the North Carolina Division of Mental Health.

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