Frequently Asked Questions

Important note: Answers to common questions are general guidelines for health plans offered by Optima Health. While most answers apply to all plans offered by Optima Health, there may be some slight differences. Please refer to member materials or contact us for information on your specific health plan.

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Enrollment

  • What documentation is required to begin the underwriting process?

    For groups enrolling 25 or more subscribers the following is needed:

    • (Employer Group Health Questionnaire (EGHP)
    • current plans / benefits
    • census split if they have more than one plan
    • current and renewing rates

    For groups enrolling 2-24 subscribers the following is needed:

    • all four pages of Optima Health’s application and health questionnaire (or Universal app) for each enrolling subscriber

  • Can I email enrollment documents to the plan?

    Yes. Enrollment documents can be sent directly to Optima Health by US mail, fax, or secure email.

  • What is the average turnaround time required to determine a group or subscriber’s eligibility or underwriting status?

    Please allow five business days for small group underwriting.

  • How do I obtain a group quote?

    Simply Request a Quote.

Products and Coverage

  • What products do you offer?

    Optima Health provides a full range of healthcare coverage products for large and small groups.

    • Plans for Large Groups: We define large groups as employer groups with 151 or more eligible employees. Our standard plan designs and funding arrangements may be offered, or they may be customized depending on the size, needs and resources of the group.
    • Plans for Mid-Market Groups: We define mid-market groups as employer groups with 51 to 150 eligible employees. Our standard plans are available with a range of coverage levels, deductibles and copayments.
    • Plans for Small Businesses: Small businesses are defined as companies with two to 50 eligible employees. Our standard plans are available with a range of coverage levels, deductibles and copayments.

    *Optima Health is the trade name of Optima Health Plan, Optima Health Insurance Company, and Optima Health Group, Inc. Optima HMO products, related Patient Optional Point-of-Service products, Point-of-Service products, and Open Access products are underwritten by Optima Health Plan. Optima Preferred Provider Organization products are underwritten by Optima Health Insurance Company. Self-funded plans are administered by Sentara Health Plans, Inc.

  • How are health plan members kept informed?

    All plan members receive:

    • member ID cards mailed to the home address on record
    • benefit information guides, usually distributed by the employer prior to enrollment
    • coverage documents that are available online and may be mailed to the member’s home at the member’s request

    In addition, members may receive:

    • member newsletter
    • other direct mail
    • Explanation of Benefits (EOB) when care is received

  • How do pre-existing conditions impact coverage?

    A pre-existing condition is any medical condition, other than pregnancy, for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period ending on the enrollment date.

    If your plan has a pre-existing condition exclusion or waiting period, you will not be covered for those specific pre-existing conditions for a period of 12 months. You may receive credit to reduce or eliminate the pre-existing condition waiting period for any creditable coverage if you were continuously covered under another health plan with no more than a 63-day break in coverage. Please refer to the Notice of Pre-Existing Condition Exclusion included with your plan documents, if applicable.

  • What qualifies as creditable coverage?

    A certificate of creditable coverage is intended to help you and your dependents in case you lose or change health plan coverage.

    Under a federal law known as the Health Insurance Portability and Accountability Act (HIPAA), you or your dependents may need evidence of coverage to reduce a pre-existing condition exclusion period under another plan, to help get special enrollment in another plan, or to get certain types of individual health coverage.

    When you change healthcare coverage, or if you or your dependents lose coverage under a health plan, the plan sponsor is usually required to provide written certification of how long you and your dependents were covered under that plan. You or your dependents can also request a certificate of creditable coverage if one is not automatically provided to you. When you enroll in an Optima Health plan we ask that you include a copy of certificates of creditable coverage for you and your dependents so that we may ensure you receive credit for your prior coverage against any pre-existing condition exclusion periods under your Optima Health plan.

    Please call member services if you have any questions about obtaining a certificate of creditable coverage. Most group health insurance (including government or church plan), individual health insurance, Medicare, Medicaid, military-sponsored healthcare (TRICARE), a program of Indian Health Service, a state health benefits risk pool, the Federal Employee Health Benefits Program (FEHBP), a public health plan as defined in the federal HIPAA regulations, and any health benefits plan under section 5(e) of the Peace Corps Act.

  • What health and wellness programs do you offer members?

    These health improvement programs provide information and lifestyle tips to reduce cardiovascular health risks and promote health.

    To take your Personal Health Assessment and for more information about all of our health and wellness programs, visit Health and Wellness.

  • When traveling, can my employees receive coverage out of the area?

    Certain Optima Health products give members the option of receiving covered services out of the area through a national carrier. Also, Optima Health provides coverage for emergency care out of the area. Contact your insurance broker or Optima Health account representative for more information.

  • How do you accommodate members located outside of the Optima Health sales area?

    In most cases these employees or dependents can be covered through Optima Health’s out-of-area PPO. Contact your insurance broker or Optima Health account representative for more information.

  • I have an employee out on disability. How long am I required to keep them on the group health insurance policy?

    A full-time, active employee who has not worked for a time period due to illness or injury (disability) may continue to be covered under the group’s health plan for up to six months.

Contact Information

  • Who are the appropriate contacts for the Peninsula and Southside business?

    Contact Us.

Release of Information

  • What is a release of information and why is it required?

    Federal and state privacy laws require us to have on file a Release of Information/Authorization of Designated Agent form whenever anyone other than the member needs to obtain and/or change the member’s health information. This form must be signed, witnessed and returned in order for it to be in effect.

Employers