Legislative Updates

Insurance Information Practices

We understand medical information about you and your health is personal and we are committed to protecting it. We use information about you to administer your benefits, process your claims, provide education and disease management programs, coordinate your benefits with other insurance carriers, create reports and research to advance the quality of care, and other transactions related to providing you and your dependents healthcare coverage.

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 information ("personal health information or PHI") that is protected by HIPAA except as necessary for treatment, payment, and health plan operations, or 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 Privacy Notice. You will receive a copy of the Privacy Notice required by HIPAA upon enrollment.

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. You will receive a copy of Optima Health’s Insurance Information Practices Notice and a copy of the Optima Health’s Financial Information Practices Notice upon enrollment.

Under HIPAA and Virginia law you have certain rights to see and copy health information about you. Under 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.

Declining Health Insurance Coverage

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact your employer group benefits administrator. You can also contact us for more information.

Certificate of 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 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 even if you have health problems. When you change health care 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. Contact us if you have any questions about obtaining a certificate of creditable coverage.

Pre-existing Conditions and Waiting Periods

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 effective date of your policy.

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.

Coverage Under More Than One Plan

If you have coverage under another health plan, that plan may have primary responsibility for the covered expenses of you or your family members. Optima Health uses order of benefit rules to determine whether it is the primary or secondary plan. Generally, the plan that covers the person as a subscriber pays first. If your dependents are covered under more than one health care plan, Optima Health has rules based on subscriber date of birth, length of coverage, and custody obligations that determine primary responsibility.

Women’s Health and Cancer Rights Act

Under the Women’s Health and Cancer Rights Act of 1998, Optima Health provides benefits for the mastectomy-related services listed below in a manner determined in consultation with the attending physician and the member:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  • Prosthesis and any physical complications resulting from the mastectomy, including lymphedema.

Coverage for breast reconstruction benefits are subject to deductibles, copays, and/or coinsurance consistent with those established for other benefits under your health plan.