An ombudsman is someone who acts as a mediator or go-between when people need help resolving a dispute. Many types of organizations, from government offices to universities, offer ombudsman services to investigate issues raised by their members. There are many kinds of ombudsmen, but what they have in common is their role investigating all sides of a conflict to help everyone involved find common ground.

Yes, My Ombudsman services are always free.

My Ombudsman helps MassHealth members who need help accessing their covered benefits and services. We are mediators and help keep the lines of communication open between members, MassHealth, providers, or other parties. We offer support, and we respect everyone's unique story, boundaries, and goals.

We help MassHealth members with all kinds of issues. Some reasons people contact us include: wanting help filing an appeal or grievance; problems getting approval for Personal Care Attendant (PCA) or other home and community-based services; disputes about a medical bill; or difficulty accessing their MassHealth benefits, like non-emergency medical transportation or medical supplies.

These are just some of the issues we can help with. If you aren’t sure whether we can work with you, you are always welcome to reach out and ask.

We serve anyone enrolled in MassHealth, including:

• Members who get their MassHealth Limited via Fee for Service (FFS), such as members who have both Medicare and MassHealth

• Members who have MassHealth Limited or Children’s Medical Security Plan

• Members enrolled in:

  • Accountable Care Organizations (ACOs)

  • Managed Care Organizations (MCOs)

  • Primary Care Clinician (PCC) plan

  • Massachusetts Behavioral Health Partnership (MBHP)

  • One Care

  • Senior Care Options (SCO)

  • Program of All-inclusive Care for the Elderly (PACE)

We can work with members of any of these types of MassHealth health plans. If you’re a MassHealth member, but you don’t know what kind of MassHealth you have, we’re happy to help you find out.

My Ombudsman can work with you one-on-one to discuss your rights and choices if you disagree with a coverage decision your health plan made. In general, you have the right to file an appeal or a grievance.

An appeal is an official way of asking your health plan (or in some cases MassHealth) to change a decision. When you file an appeal, you get to tell your health plan or MassHealth in your own words why you disagree with their decision. The provider who requested the service or care that was denied can also help with this process.

A grievance is a formal way of telling your health plan that you are not happy with their actions. This type of complaint is a way to get your concerns “on the record,” but it may not result in a different outcome or change their decision. The plan is still required to respond (usually in writing) to your concerns.

My Ombudsman can help you understand why your service was denied, explore your choices, and help you navigate the process of an appeal or grievance. We can’t represent you in an appeal, which means we can’t serve as your advocate and tell MassHealth or your health plan to make a decision in your favor.

There are many reasons why a member can receive a denial letter. For example: Maybe MassHealth or your health plan needs more information. Or maybe the service requested is not something MassHealth or your health plan usually covers. Maybe the health plan and doctor disagree about whether the service is medically necessary. Or, the reason may be something else altogether.

If you receive a letter like this, we suggest reading it carefully and holding onto it. The letter should describe the reason for your denial and the next steps you can take, like filing an appeal. Contact your MassHealth or your health plan if you need help understanding what the letter says. If you need further assistance, you are welcome to contact My Ombudsman. We can discuss the letter together to see if we can help you understand the health plan’s decision. We can also discuss your options, including your right to ask for an appeal.

If you’ve tried contacting your doctor, your pharmacy/supplier, and your health plan without success, call My Ombudsman and we will try to help determine why you are unable to get the refill. If it is an insurance-related issue, we will work with your plan and your care team to try to find a solution. Our hours are 9am-4pm, Monday-Friday. We are closed on major holidays.

NOTE: If you are experiencing a life-threatening emergency, please call 911 or go to your local emergency room.

No, My Ombudsman works exclusively with MassHealth members. Please contact the plan’s member services department. The phone number is usually printed on your member ID card or can be found on the health plan’s website.

No, My Ombudsman works exclusively with MassHealth members.

The Health Connector Consumer Ombudsman can help resolve problems related to Health Connector billing, enrollment, website function, or customer service. For any other issue, contact your insurance plan’s member services department. The phone number is usually printed on your member ID card or can be found online.

Yes. We can work with anyone who is a current member of MassHealth, whether they have a disability or not. We support DPC’s mission to advance disability rights by protecting everyone’s access to healthcare. Our staff includes people from diverse professional, educational, cultural, linguistic, and personal backgrounds because the people who contact us come from all walks of life.

If your question or concern is related to a MassHealth benefit, we can help. If you do not, we will still do our best to refer you to the right place. One common place we refer to is SHINE (Serving the Health Insurance Needs of Everyone) They provide free health insurance information and counseling to all MA residents with Medicare. You can call SHINE at (800) 243-4636.

My Ombudsman is not a part of MassHealth or any health plan. When you contact My Ombudsman, the person you talk to is not a MassHealth employee. We are an independent program run by a non-profit organization.

The MassHealth Customer Service Center can help all MassHealth members, with a wide range of questions and concerns. For example, they can provide information about your eligibility for MassHealth coverage and help you enroll in a MassHealth health plan. They can help you apply for MassHealth, give information about your health plan benefits, or help you replace a lost MassHealth member ID card. You can call the MassHealth Customer Service Center at (800) 841-2900.

My Ombudsman works with people who are already enrolled in MassHealth (members.) Our job is to help members with all kinds of questions and concerns about accessing their health plan’s covered benefits and services. We offer “hands-on” support while we work with you to investigate and resolve your problem.

Yes, if you are a SCO member or a One Care member, we can help you. We can work with you and your care team to find a solution to your issue.

Our staff cannot act as personal representatives and we do not give any legal advice. We can provide contact information for legal advocacy organizations, usually ones who work at no or low cost. We can also discuss your right to have a non-legal representative at an appeal hearing.

No, a Long-Term Care Ombudsman is an advocate working to resolve problems related to the health, welfare, and rights of individuals living in nursing or rest homes. These Ombudsmen visit facilities on a regular basis and offer a way for residents to voice their complaints and work towards a resolution with staff.

My Ombudsman serves MassHealth members when they have a question or problem with their health plan benefits or services, whether they are living in a long-term care facility or not.

You can call (800) 243-4636 to connect with your local long-term care ombudsman. Or you can find the contact information for your local long-term care ombudsman by clicking here.

Sometimes people discover that their MassHealth coverage has ended or changed, and they don’t know why. As a result, they can’t access important services like prescriptions, mental health care, or treatment for chronic conditions. If you are in this kind of situation, we suggest calling the MassHealth Customer Service Center at (800)-841-2900 or the Health Care for All helpline at (800)-272-4232. You can also call My Ombudsman and we will explore options for getting access to any medically necessary services as soon as possible.

Yes. MassHealth covers medically necessary COVID-19 treatment ordered by a health care provider, for all members, no matter what kind of MassHealth coverage or plan they have. Getting tested or treated for COVID-19 when it is medically necessary is free and will NOT impact your immigration status. Learn more about what is covered from the Masshealth website: https://www.mass.gov/info-details/masshealth-coronavirus-disease-2019-covid-19-applicants-and-members#masshealth-coverage-for-testing-and-treatment-of-covid-19-

Not every COVID-19 testing site accepts MassHealth, and different testing sites accept different MassHealth health plans. Check with your healthcare provider, insurance plan, care manager, or MassHealth’s COVID-19 information website for applicants and members to find a covered or free testing site near you.

All One Care members have access to a Care Partner, Care Manager, or Care Coordinator and a care team. Your Care Partner, Care Manager, or Care Coordinator’s job is to make sure everyone on your care team is working together to help you get what you need. One Care members also have the right to add a Long-Term Supports (LTS) Coordinator to their care team for additional support. If you have needs you feel are not being addressed, start by talking with your Care Partner, Care Manager, or Care Coordinator, your providers, and/or other members of your care time, like your LTS Coordinator. If you’ve already talked to your care team and you need more help, you can contact My Ombudsman.

One Care members can attend monthly meetings held by the One Care Implementation Council (IC). This committee plays an important role in promoting accountability and transparency within One Care. Click here to learn more. All One Care plans also have a consumer advisory Council (CAC) that members can join, and plans may have other ways members can provide feedback. Contact your plan to find out how you can get involved.

Yes. Your One Care plan covers all the same DME as MassHealth and Medicare, and may cover additional DME. Everyone’s needs are different, so work with your care team - your healthcare providers and your Care Partner, Care Manager, or Care Coordinator to find out if your DME will be covered. Your care team can also help coordinate fittings, repairs, and more. There is no out-of-pocket cost for DME.