In 1993 CalPERS implemented the Ombudsperson Program for the Health Benefits Program. The purpose of this new program was to provide specific assistance to those members who had extraordinary enrollment or benefit problems. There are times when a member is involved with an unusually complex enrollment change or embroiled in a dispute over a covered benefit and needs special assistance. The CalPERS Board believed that additional assistance was appropriate for these types of cases and implemented the Ombudsperson Program to address these unique problems. The ombudspersons have access to both eligibility information and health plan benefit data and are able to cut across the traditional lines of the organization to bring the issue to closure quickly.
The program has been very successful and is limited only by staff availability. Retired members who do not have the support and advice of peers at the work site have found this service to be particularly helpful in coping with the complexities of benefit and enrollment problems. The complex nature of enrollment systems and benefit policies can be confusing to consumers. The Ombudsperson Program is an attempt to provide additional support and assistance to those members who have difficulty navigating through the health care system. It is an example of the commitment that the CalPERS Board has made to customer service.
A major strength of the CalPERS Health Benefits Program is that members can appeal directly to the Board for review of their complaints once they have exhausted their appeal rights with their health plan. Members are informed of this option annually during the open enrollment period and are given the address and telephone number of the Member Service Unit, which is staffed by CalPERS Health Benefits Program employees. These staff members answer questions and advise members of their right to appeal an issue once it has been adjudicated by the health plan. This offers the members the opportunity to explain their problem to a neutral third party who can intercede on their behalf, when appropriate, or advise the members of their options.
The final element of customer service oversight is the development and distribution of information describing the eligibility