Frequently Asked Questions

• What plans do you offer?

  Optima Health offers many products for large and small group employers, such as Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Consumer Directed Health plans. These products include: Optima Vantage, Optima Plus, Optima POS, Optima Equity, and Optima Design.

  OptimaFit^® Individual & Family Plans are offered for people who do not have coverage through their employer.

  Optima Health also offers a health plan for Virginia Medicaid and FAMIS beneficiaries called Optima Family Care, as well as Optima Health Community Care, a managed long-term services support plan. Our Medicare Advantage and Medicare Advantage Special Needs plans include everything offered by original Medicare, plus more.

• Do you offer an individual product?

  Yes. Whether you go to school, are between jobs, are ready to retire but are not yet eligible for Medicare, have a family, or don’t have a health plan through your employer, Optima Health has a variety of health plans to meet your unique needs.  Learn more about OptimaFit Individual & Family Plans.

• When and where do I call if I have questions?

  Refer to this section of the website for answers to commonly asked questions. If you still have questions, contact member services.

• What is the Treatment Cost Calculator?

  Thank you for exploring the Optima Health Treatment Cost Calculator. Optima Health developed this tool to help our health plan members make informed decisions that are best for their health and their budget.

  These frequently asked questions (FAQs) provide an overview of how Treatment Cost Calculator estimates are produced, what costs are included in each estimate, and some helpful hints to help users take full advantage of the various resources available in the tool. These FAQs will evolve based on the user experience, so check back for updates.

  Frequently Asked Questions about the Treatment Cost Calculator

https://member.optimahealth.com/account/sign-in

• I have not received my member ID card but need to see my doctor. What should I do?

  Contact member services. If your application has been processed they will be able to give you your unique member ID number. This number allows a doctor to verify your eligibility and bill your services to the health plan. If your doctor requires you to present a card at the time of service, you can sign in online or on the Optima Health mobile app to view a digital version of your member ID card.

• Why do I need to carry my member ID card?

  Your member ID card identifies you as a covered member of Optima Health. In addition, it provides information such as copayment amounts, applicable deductibles, your member ID number, and important phone numbers and addresses.

• I received a new member ID card in the mail but I already have one. Should I throw the new one away?

  No. Unless you ordered a new card online or through member services the only reason you will receive a new card is if important information on it has changed. Always show your member ID card to your doctor when you receive a new one.

• How do I request a new member ID card?

  You can sign in online or with the Optima Health mobile app to view a digital version and order a hard copy of your member ID card.  You may also call member services. Once ordered, the card should arrive in 7-10 business days.

• Do you need nurse advice?

  Call the number on the back of your member ID card.
  
  Remember, in an emergency always call 911 or go to the nearest emergency department.

• What should I do if I get sick or hurt after business hours or during the weekend?

  If you have an illness, injury, or condition that occurs during an evening or weekend, you should visit an urgent care center or call the 24/7 Nurse Advice Line number located on the back of your member ID card.

• What happens when I call the 24/7 Nurse Advice Line?

  A registered nurse will ask you to describe your medical situation in as much detail as possible. Be sure to mention any other medical conditions that you have, such as diabetes or hypertension.

  Depending on the situation, you may be advised about appropriate home treatments or to visit your doctor to seek care.  If necessary, the nurse may direct you to a Plan urgent care center or Emergency Department.

  The 24/7 Nurse Advice Line nurses have training in emergency medicine, acute care, OB/GYN, and pediatric care. The staff are well-prepared to answer medical or behavioral health questions for members and their dependents. However, since they are unable to access medical records, they cannot diagnose or medically treat conditions, order labs, write prescriptions, order home health services, or initiate hospital admissions or discharges.

• What should I do if I have an emergency?

  In any life-threatening emergency situation, always go to the closest emergency department or call 911.

  If you received emergency care and are admitted, you or a family member should contact Optima Health within 48 hours (two business days) or as soon as medically possible. This enables Optima Health to arrange for appropriate follow-up care, if necessary. Please note that in each of these situations care may be reviewed retrospectively to make sure it met the criteria for coverage of emergency care treatment.

• How can I tell if it is an emergency?

  An emergency is the sudden onset of a medical condition with such severe symptoms or pain that a person with an average knowledge of health and medicine (prudent layperson) would seek medical care immediately because there may be serious risk to your physical health, your mental health, or that of your unborn child.

  Some examples of situations that would require the use of an Emergency Department include but are not limited to:

  • heart attack/severe chest pain
  • trouble breathing
  • stroke
  • poisoning
  • loss of consciousness
  • head trauma
  • broken bones
  • seizures
  • severe bleeding
  • loss of vision
  • fever over 104°F
  • vaginal bleeding when pregnant
  • plans to harm yourself or others

• What conditions generally do not require Emergency Department treatment?

  The following conditions do not ordinarily require Emergency Department treatment, and may be more appropriately treated in your doctor’s office, or at a Plan urgent care center:

  • sprains or strains
  • chronic conditions such as arthritis, bursitis, or backaches
  • minor injuries and puncture wounds of skin
  • refill and renew medications
  • chronic illness
  • vaccines
  • long-term urine/bowel issues
  • most behavioral health needs
  • flu, sore throat, fever
  • toothache
  • cough/cold/runny nose
  • throat pain or sore throat
  • ear pain
  • pain/burning in urine
  • headache
  • nausea/vomiting
  • loose stools/diarrhea
  • fever less than 104°F
  • rash
  • back pain
  • penile/vaginal discharge
  • minor injuries, cuts, burns

• What is the difference between an Emergency Department and an urgent care center?

  An Emergency Department is designed, staffed, and equipped to treat life-threatening conditions. An urgent care center is a more appropriate place to seek treatment for sudden acute illness and minor injuries when your doctor’s office is closed or not available. Copayments and coinsurance amounts for Emergency Department visits are generally higher than copayments for urgent care visits. If you are transferred to an Emergency Department from an urgent care center, you will be charged an Emergency Department copay/coinsurance.

• Do I need to contact Optima Health or my PCP before going to the Emergency Department or urgent care center?

  No. However if you are unsure whether to visit an Emergency Department or urgent care center, you can call the 24/7 Nurse Advice Line at the number on your member ID card.

• What if I become ill when I am outside of the Optima Health service area?

  Your plan includes coverage for emergency services when you are outside the service area. If you have an unexpected illness or injury when outside of the service area you should call the 24/7 Nurse Advice Line at the number listed on the back of your member ID card. In any life-threatening emergency situation always go to the closest Emergency Department or call 911.

  Remember, Optima Health may review all Emergency Department care retrospectively—after the fact—to determine if a medical emergency did exist. If an emergency did not exist, you may be responsible for payment for all services.

• What if I need to be hospitalized?

  If you received emergency care and are admitted, you or a family member should contact Optima Health within 48 hours (two business days) or as soon as medically possible. This enables Optima Health to immediately begin reviewing your situation and arrange for appropriate follow-up care. Remember all emergency care may be reviewed retrospectively to make sure it met the criteria for coverage of emergency/urgent care treatment.

  If you are admitted to a hospital outside of Optima Health’s service area, call member services or the 24/7 Nurse Advice Line at the number listed on your member ID card. Be prepared to give the following information:

  • member name
  • reason for treatment
  • hospital name
  • city and state where treatment is occurring
  • name of treating doctor

  The doctor or hospital may also call clinical care services.

• What happens once I am admitted to the hospital?

  As part of your Optima Health coverage, a case manager will follow your case from beginning to end. They will review your chart daily, check your progress, and arrange for your continuing care needs after you leave the hospital.

• What about mental health services?

  You may contact either Optima Behavioral Health at 757-552-7174 or 1-800-648-8420, or call your PCP for guidance prior to seeing a mental health provider.

• Is a referral for mental health inpatient services required?

  No. If you need to be hospitalized, your mental health provider (not your PCP) will arrange for your admission to the appropriate in-network facility

• Is there a way to handle emergencies for mental health?

  Yes. Remember, to always call 911 in an emergency or to visit the nearest Emergency Department. For non-emergency behavioral health information after hours, please call the 24/7 Nurse Advice Line at the number listed on the back of your member ID card.

• How does Optima Health protect my personal information?

  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans protect the confidentiality of your private health information. Optima Health will not use or further disclose HIPAA protected health information (PHI) except when necessary for treatment, payment, and health plan operations, as permitted or required by law, or as authorized by you.

  A complete description of your rights under HIPAA can be found in the Sentara Healthcare Integrated Notice of Privacy Practices. A copy of the notice will be included in your Evidence of Coverage (EOC) or Certificate of Insurance (COI) when you enroll. You can view a copy of our privacy notice online.

  The Commonwealth of Virginia also has laws in place to protect the privacy of our members’ insurance information. We will not release data about you unless you have authorized it, or as permitted or required by law. Optima Health requires an Authorization for Use or Disclosure of Medical Information (Designated Agent) form whenever anyone other than the Optima Health member needs to obtain and/or change health information. To download a copy of the form, sign in and visit Forms and Documents, or call member services at the number on the back of your member ID card.

  Under HIPAA and Virginia law you have certain rights to see and copy health information about you. Through HIPAA, you have the right to request an accounting of certain disclosures of the information and under certain circumstances, amend the information. You have the right to file a complaint with Optima Health or with the Secretary of the U.S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.

• What is a tier?

  Optima Health uses a prescription drug formulary. The formulary is a list of drugs that are covered under your plan. Most Optima Health plans have a four (4) tier formulary. The tier your drug is placed in will determine your copay or coinsurance amount. Drugs in Tier 1 will have the lowest out-of-pocket cost to you. Drugs in higher tiers will cost you more. To view an abbreviated version of this list or calculate drug costs, sign in and visit Pharmacy Resources under the Doctors and Medications tab.

• How do I know what I'll pay out of pocket for a prescription medication?

  Your prescription drug tiers are listed in your plan benefit documents. You must pay your applicable copayment/coinsurance when you pick up your drug from the retail pharmacy. Some plans may also have a separate pharmacy deductible. If your plan includes benefits for mail-order prescription drugs, you may be able to get certain maintenance drugs by mail for lower out-of-pocket costs. To view an abbreviated version of this list or calculate drug costs, sign in and visit Pharmacy Resources under the Doctors and Medications tab.

• Why do some drugs require pre-authorization?

  Some drugs require pre-authorization by Optima Health in order to be covered. Your prescribing doctor is responsible for initiating pre-authorization. You should also check your plan documents to see what medications may be excluded from coverage. You can view your plan documents by signing in and choosing Benefits and Coverage from the menu. Optima Health may also establish monthly quantity limits for selected medications.

• Can I order my maintenance prescription drugs through the mail?

  Yes, if you have a pharmacy benefit and it is administered by Optima Health. Visit the Prescription Home Delivery page for instructions.

• What is a primary care physician (PCP), and why are they recommended?

  Your Plan primary care physician (PCP) is your point of contact to coordinate your healthcare needs. They can provide both the first contact for an undiagnosed health concern, as well as oversee continuing care of varied medical conditions. Depending on your PCP for routine medical care and guidance when seeking care within the Optima Health network can increase your satisfaction with the plan. You will be asked to select an in-network or Plan PCP for yourself and each of your eligible dependents when you enroll.

• How do I choose a PCP?

  When you enroll in an Optima Health plan, you will be asked to choose a PCP for yourself and each of your dependents. New members can often continue relationships with their present doctor or select a doctor with an office more convenient to their home or work address. You have the right to choose any PCP who participates in our network and who is available to accept you and/or your dependents. For children, you may choose a participating pediatrician as their PCP.

  You can review a list of participating providers for your plan online.  You can choose or change your PCP online when you sign in, select Change Primary Care Physician from the menu, and follow the onscreen instructions. In most cases, your PCP selection will be effective the next business day.

  Please note, you do not need prior authorization from Optima Health or from any other person, including your PCP, to access obstetrical or gynecological or other specialty care from a healthcare professional in our network. The healthcare professional may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or other Plan requirements.

  If you have not seen your designated PCP within the last 24 months, please contact your PCP’s office or member services to ensure that the office still lists you as a patient. Having your correct PCP on file ensures that any correspondence or other outreach to your PCP is accurate.

• What about my spouse and children? Do we all need to have the same PCP?

  You have the right to choose any PCP who participates in our network and who is available to accept you and/or your family members. You may select the same PCP for everyone, or each member can select their own unique PCP.

  Generally, adults choose a family practice or internal medicine doctor for their PCP. For children, you may choose a participating pediatrician as their PCP.

• What if my Plan doctor leaves the Optima Health network?

  If your Plan doctor leaves the network, Optima Health will notify and assist you in finding a new doctor or facility. If you are in active treatment with a doctor who leaves the network you can request to continue receiving healthcare services from the doctor for at least 90 days. If you are beyond the first trimester of pregnancy you may be able to remain with that doctor through the provision of postpartum care directly related to the delivery. For a terminal illness, treatment may continue for the remainder of the member’s life for care directly related to the terminal illness.

Referrals are not required for any Optima Health plans.

• What if I need to see a specialist?

  You do not need a referral from your PCP for specialist care. If you and your PCP decide you need to see a specialist, your PCP will coordinate your care and you can make your own appointment. Before you see a specialist, you should confirm that the specialist is in Optima Health's network. Visit Find a Doctor or contact member services at the number on the back of your member ID card to make sure that your specialist is in the network.

• What if my doctor directs my care to a non-network doctor?

  It is your responsibility to ensure that you are using in-network doctors and facilities. If you have an Optima Vantage or HMO plan and your doctor directs you to a non-network doctor, you will be responsible for payment of these services. If you have a POS or Plus PPO plan, you have the option of using in-network doctors or out-of-network doctors. Claims from out-of-network doctors will be paid at a reduced benefit level and you will usually pay higher deductible, copayment, and coinsurance amounts. To find an in-network doctor, use the Find a Doctor or Find a Facility search feature, download a Provider Directory, or call member services at the number on the back of your member ID card.

• Is my specialist authorized to order diagnostic or x-ray tests for me?

  Yes, but some tests may require pre-authorization by the plan.

• Do I need a referral for my annual GYN exam?

  No. Your plan does not require referrals. Female members may schedule an appointment for a routine annual exam with any OB/GYN in Optima Health’s network.

• Can an OB serve as my primary care physician while I am pregnant?

  Yes, during your pregnancy, your OB can serve as your PCP. As a Plan member, you are automatically eligible for Optima Health’s Partners in Pregnancy program. This program is designed to provide education and support to pregnant women. If you would like more information about the program, simply call 1-866-239-0618.

• Who is responsible for making sure the doctors I see and the services I receive are covered under my health plan?

  It is your responsibility to ensure that you are using in-network or Plan doctors and facilities.

  If you have an Optima Vantage or HMO plan and your Plan doctor directs you to a non-Plan provider, you will be responsible for payment of these services.

  If you have a POS or Plus PPO plan, you have the option of using Plan providers or non-Plan providers.  Claims from non-Plan providers will be paid at a reduced benefit level and you will usually pay higher deductible, copayment, and coinsurance amounts.  You may also be balance billed for any charges in excess of the Plan’s allowable charges.  To find a Plan provider, use the Find a Doctor, or Find a Facility search feature, download a Provider Directory, or call member services at the number on the back of your member ID card.

• Do you offer an individual policy for the self-employed or retired?

  Yes. Optima Health offers individual plans for individuals who do not have coverage through their employer or have retired but are not Medicare-eligible. Discover your Individual Plan options.

  If you were previously covered by Optima Health and had a qualifying event, you may qualify for COBRA.

• How do I get insurance coverage?

  You can get a free quote or apply online, or you can call an Optima Health personal plan advisor at 1-800-741-4825.

  Discover your Individual Plan options.

• I was covered through Optima Health and lost my job. Does that mean that I no longer have the option of insurance coverage?

  No. If you were covered by Optima Health and had a qualifying event, you may be able to obtain and pay for coverage at the same benefit level through COBRA. You may also be eligible to enroll in an Individual & Family Plan. Contact your Benefits Administrator for help.

• I’m having trouble signing in. What can I do?

  Ensure you are following our username and password requirements:

  • Usernames must begin with a letter, and can include only letters (a-z or A-Z), numbers (0-9), and underscores (_).
  • Usernames cannot include spaces or special characters and are not case sensitive.
  • Usernames can be a maximum of 20 characters long.
  • Passwords must be 8 - 64 characters long
  • Passwords cannot contain your username, first name or last name
  • Passwords cannot contain the words "Sentara", "MyChart", or "MyHealth" using any case
  • Passwords cannot contain 3 or more repetitive or sequential characters (i.e. "aaa" or "123")
  • Passwords cannot be a dictionary word by itself

  Please note that if you choose a password that we identify as having previous security concerns, we will ask you to choose a different one.

• How do I register?

  If you are age 14 or older and a covered member of the health plan, you can register on your desktop or on the Optima Health mobile app. You will need to have your member ID number, Medicaid number, Medicare number, or SSN available to complete the registration process. After you have registered, you can access your account on both the website and the mobile app.

  Register now.

• I have forgotten my username and/or password. What do I need to do?

  If you have forgotten your password, select Forgot Password. The secret answer you supplied during the registration process will allow you to reset your password. Keep in mind that the answer to your secret question is case sensitive. If you can’t remember the answer to your secret question, you will need to contact member services to have your password reset.

  If you have forgotten your username you can complete the first step of the registration process again to recover your username.  If you have previously set up a username, your username will appear at the top of the registration page after you have submitted the registration form. You may also contact member services to find out your username.

• Who should I contact for help?

  Contact member services if you need assistance.