Healthy Connections Prime Ombudsman

Healthy Connections Prime Ombudsman helps older adults who are enrolled in Healthy Connections Prime address any concerns or conflicts that may interfere with navigating and coordinating their health coverage through Medicare and Medicaid.

Many people aged 65 years and older experience issues with navigating and coordinating their health care coverage. Some of the issues they face may include:

  • Continuity of care
  • Appeals and grievances procedures
  • Medicaid recertification
  • Enrollment and disenrollment
  • Balanced billing

This is an issue because of fragmented and sporadic coordination of benefits between Medicare and Medicaid.  Statistics from SCDHHS indicate a high level of emergency room visits and re-hospitalizations as a result of poor medical compliance and inconsistent care.

Healthy Connections Prime Ombudsmen

What do we do?

  • We help members to navigate the process and educate them on their rights and benefits.
  • We assist with Medicaid recertification process and make sure that members are not billed for out of pocket costs.
  • We work with the member/and or plans to assist with the appeals and grievance process.
  • We educate the members, caregivers, stakeholders, and community via telephone, walk-in, emails, or outreach events.

Successes

  • Assisted members to have their overdue claims paid (more than $100,000 settled)
  • Assisted members with recertification to maintain eligibility with Medicaid
  • Prevented inappropriate discharges
  • Raised awareness of educational needs of plans and gaps in coverage
  • Ongoing, we track trends and make recommendations for program improvement
  • Continue to serve as a liaison between member’s plan and providers

For more information, please contact the Healthy Connections Prime Ombudsman at the Lieutenant Governor's Office on Aging at 1-844-477-4632 or visit the Healthy Connections Prime Ombudsman website.