One risk of the dual eligible integration models is that new incentives will arise for plans and providers to deny needed care. To address this risk, enrollees should have access to an independent ombudsman who can provide individual assistance and also identify systemic problems in the model. The ombudsman should be funded by the state or participating managed care plans and should have expertise in the delivery of Medicare and Medicaid benefits, including Long-Term Services and Supports and Behavioral Health services, to seniors and persons with disabilities. The strongest models house this function within an organization that is known and trusted by the aging and disability communities.
The State of Wisconsin has established a state-funded ombudsman program specifically to assist enrollees in the state’s Family Care and IRIS programs. The Family Care program, a managed-care option within the state’s Medicaid program, covers long-term services and supports (LTSS) such as nursing facility care, personal care services, and home health services. The IRIS program — IRIS is the acronym for “Include, Respect, I Self-Direct — is a Medicaid waiver program that funds self-directed services for Medicaid beneficiaries in their own homes.
The ombudsman program is targeted to enrollees under age 60 (as enrollees of age 60 or older have access to assistance provided under the state’s long-term care ombudsman program). The Family Care/IRIS ombudsman program has a goal of providing at least one advocate for every 2,500 enrollees under age 60. Wis. Stat. § 46.281(1n)(e); see also Wis. Stat. § 16.009(2)(p) (authority of long-term care ombudsman program). The available advocacy services must include all of the following:
- Information and assistance in obtaining needed services.
- Information and assistance in pursuing complaints and appeals.
- Negotiation and mediation.
- Case advocacy assistance in interpreting relevant law.
- Individual case advocacy in administrative hearings and court proceedings relating to program benefits.
Wis. Stat. § 16.009(2)(p)(1)-(5).
The Family Care/IRIS ombudsman program is operated by Disability Rights Wisconsin under a contract with the Wisconsin Department of Health Services, and completed its third year of service in 2011. The contract is available at www.dhs.wisconsin.gov/LTCare/Memberinfo/disombuds.htm.
Annual requests for ombudsman services have increased from 98 to 426 and then to 606 over the program’s first three years. Relatively few cases have been taken through an administrative hearing – 2.6% of cases during the second year, and 1.9% during the third year. Disability Rights Wisconsin, Family Care and IRIS Ombudsman Program, Year 3 Annual Report, at 1 (Oct. 1, 2011). The most common issues presented in the third year were service reduction (10%), enrollment and eligibility problems (9%), relocation (8%), disenrollment (7%), and the IRIS financial allocation (5%).