Ombudsman programs can offer beneficiary protections as part of Medicaid managed care programs. These programs are particularly important for beneficiaries with complex physical and behavioral health conditions, including many dually eligible individuals. For the demonstrations under the Financial Alignment Initiative, the Centers for Medicare & Medicaid (CMS) and states incorporated ombudsman programs to help to resolve enrollees’ problems and alert Medicare-Medicaid Plans (MMPs), states, and CMS of emerging trends and issues. This technical assistance brief compares approaches that states took in structuring ombudsman programs and discusses the benefits and challenges of both models. It also examines the services offered by ombudsman programs and the value these programs have brought to the demonstrations. This brief is designed to help state Medicaid agencies that are developing beneficiary support systems or implementing new integrated care programs to better understand the full range of beneficiary needs within their dually eligible populations and how ombudsman programs or similar support systems could bring value to their efforts.
Helping states develop integrated programs for individuals who are dually eligible for Medicare and Medicaid