Code of the District of Columbia

§ 7–2071.04. Duties.

The Ombudsman Program shall provide the following accessible services:

(1) Assist consumers in resolving problems concerning health care bills, health coverage, and access to health care by referring consumers to appropriate regulatory agencies when their problems are within an agency’s jurisdiction, guiding consumers through existing complaint processes, and assisting consumers in informally resolving problems through discussions with their health benefits plans, the HealthCare Alliance, or other providers;

(2) Assist consumers in understanding their rights and responsibilities as health benefits plan members, HealthCare Alliance members, or members of other provider plans, including appeal processes and how to use them, and how to access appropriate medical information;

(3) Educate consumers about health benefits plans, managed care health plans, and their health benefits plan options, or other health care options available for uninsured consumers;

(4) Comment on behalf of consumers on related health care policy legislation and regulations in the District;

(5) Help uninsured District residents access Medicaid or other health care options;

(6) Identify, investigate, and help resolve complaints on behalf of consumers and assist consumers with the filing, pursuit, and resolution of formal and informal complaints and appeals through existing processes, including internal reviews conducted by health benefits plans, grievance and appeals processes for the HealthCare Alliance, fair hearings available to Medicaid consumers, external reviews before independent review organizations, and any other administrative appeals that may be available under District or federal law;

(7) Refer consumers, when appropriate, to other existing organizations for assistance and work jointly with other consumer organizations, as appropriate;

(8) Work with health care providers to develop working relationships that enhance coordination and referrals;

(9) Make appropriate referrals to the Department of Insurance, Securities, and Banking, the Office of Fair Hearings, the Office of Administrative Hearings, the Grievance and Appeals Office of the Department of Health, Health Care Fraud Units, the Long-Term Care Ombudsman, the Health Insurance Counseling and Assistance Program serving District Medicare beneficiaries, and the Center for Health Dispute Resolution; and

(10) Provide information to the public, government agencies, the Council, and others regarding problems and concerns of consumers and make recommendations for resolving those problems and concerns.


(Apr. 12, 2005, D.C. Law 15-331, § 5, 52 DCR 1981.)