Department Violates State and Federal Laws Over Ombudsman Services
A bipartisan group of legislators joined Consumers for Affordable Health Care and Maine residents to protest a decision by the Department of Health and Human Services (DHHS) to end contract ombudsman services through the state Medicaid Managed Care program.
The decision violates both state and federal law, and leaves Maine families without the services they need to navigate a complex health care system that includes MaineCare, the health insurance marketplace and private insurance.
“Contracts change all the time. I understand that. And the Department has an obligation to review contracts to make sure that the work they are paying for is needed and is getting done,” said Rep. Karen Vachon. “But the Department also has an obligation to follow the law and to take care of Maine residents. In this case, they are Maine residents who need help to navigate our confusing health care system to get coverage.”
In June, DHHS abruptly eliminated its long-standing contract with Consumers for Affordable Health Care to provide ombudsman services through Medicaid Managed Care section of state law.
“The Department has consistently set up roadblocks for families seeking health care and other forms of assistance, and it has shown a disregard for the law, for rulemaking and for the Legislature in general,” said Rep. Linda Sandborn. “The Legislature has spoken and said that it requires the department to provide the ombudsman and navigation services. The Department is ignoring the law, and that’s hurting real people who need help figuring out how to get health insurance.”
The contract to provide the ombudsman and navigation services does not use state dollars. It is funded through a combination of federal dollars and privately raised matching dollars.
“Mainers need these services now more than ever,” said Emily Brostek, executive director of Consumers for Affordable Health Care. “Maine is the only state in the country where the number of kids without health coverage is going up. Too often, families are going without coverage or care because they’ve been told they don’t qualify for services when in fact they do. These families need an ombudsman program that is fighting for them – not just because federal and state law require these services, but because they deserve it.”
This contract does not cost the state any money
- It is funded entirely by federal matching dollars and funds raised privately by CAHC.
- The state will have to increase its General Fund budget (or if excess staff is available, forego other efficiencies) to provide these services.
The services performed under this contract are required by federal and state law
- This contract allows DHHS to deliver outreach services REQUIRED by Federal law without using any general fund dollars nor tying up any State FTEs to do so.
- State law REQUIRES that DHHS contract with a Maine nonprofit to provide services of this nature for as long as it doesn’t cost the state any general fund money. This contract meets that standard.
This contractual relationship saves DHHS both time and money
- CAHC has performed the duties under this contract since 2006. We are good at it.
- Without CAHC’s services, DHHS would have to invest in training personnel to provide the outreach.
- Because of CAHC, fewer people go to DHHS with questions. CAHC educates on ALL options (Marketplace plans, FQHCs, free clinics, PHIP, prescription assistance, and hospital free care), thus minimizing the impact of required outreach on MaineCare spending.
- CAHC resolves eligibility disputes informally, which helps DHHS reduce costly and time-consuming consumer appeals. Without CAHC there will be more formal appeals, more state employee work.
- The number served under this contract has increased dramatically. HelpLine calls alone have increased nearly six fold (from 1,622 in 2006 to over 6,700 in 2014). Just answering the calls would require tremendous DHHS staff time. Still more resources would be used to screen for all options.
“Last year, Maine families called the Consumers for Affordable Care helpline nearly 6,000 times because they were having trouble navigating a complex health care market place or because they couldn’t make progress with the Department of Health and Human Services,” said State Sen. Geoff Gratwick. “The ombudsman services CAHC has provided to our state, including this HelpLine, are critical to Maine families.”
Consumers for Affordable Health Care is a nonprofit advocacy organization committed to helping all Maine people obtain quality, affordable, health care. For more information, visit:http://www.mainecahc.org/about-us/