Optima Health | Health Reform

Health reform is at the forefront of most Americans' minds. We at Optima Health are no exception.

As we all work to ensure compliance with the new law, we recognize that our members, providers, employers and brokers have many questions. Visit this section of our website often as we will post frequently asked questions and other information that relates to health reform and our plans.

Statement from Optima Health

For more than 25 years, Optima Health has been committed to providing quality, cost-effective healthcare for our members. Today’s Supreme Court ruling does not change that. As the reform law is fully implemented expanding coverage to hundreds of thousands of Virginians who have lacked coverage, Optima Health will continue offering plans that provide affordable choices to our small group, large group and individual members. We will also continue providing comprehensive programs focused on improving the health of our members in an effort to manage overall healthcare costs.

Michael M. Dudley
President and CEO, Optima Health

PPACA Fees and Taxes for Fully Insured Groups

In accordance with the Patient Protection and Affordable Care Act (PPACA), Optima Health is required to pay annual fees and taxes necessary to fund provisions within the law.

Learn more about PPACA Fees and Taxes for Fully Insured Groups

Frequently Asked Questions About Health Reform

Below is a list of common questions and answers related to health reform and how Optima Health is handling changes brought about by health reform. Please check back regularly for the most up-to-date information on how Optima Health is complying with the new health reform regulations.

Download frequently asked questions about health reform

Download Kaiser Health News publication: "After The Ruling: A Consumer’s Guide"

List of Preventive Services Provided with No Member Cost-Sharing

Certain recommended preventive care services will be covered with no member cost sharing, including Copayments, Coinsurance, or Deductibles when received from an Optima Health in-network plan provider. Depending on your plan, if you see an out-of-network or non-plan provider for preventive care you will have to pay a Copayment, Coinsurance, or Deductible. Below is a list of these preventive care services from the official regulations under the law, including women’s preventive effective August 1, 2012. This list is subject to change based on future regulations; please continue to check back for updates. In addition, please contact Optima Health Member Services at the number on the back of your member ID card or refer to your plan documents for a complete list of benefits and specific requirements for documentation or prescriptions required prior to receiving these services.

Download the list of preventive services provided with no member cost-sharing

Grandfathered Health Plans

Optima Health will be extending grandfather status for:

Eligible Members of Individual Plans
Self-Funded Employers
Companies with Plans Subject to Collective Bargaining Agreements

Companies and individual members that have the option to grandfather health plans should carefully review and consider their obligations, opportunities and risks under the new law.

Optima Health made a number of considerations in developing its policy:

Administrative complexities and costs associated with grandfathering.
The number of employers potentially willing to comply with rules for grandfathering over the next several years.
Members’ access to new mandates that are included in provisions of Subtitles A and C of Title I of the Affordable Care Act

Medical Loss Ratio (MLR)

As part of the Patient Protection and Affordable Care Act (PPACA) that was signed into law March 2010, insurers selling policies to individuals or small groups are required to spend at least 80 percent (80%) of premiums on direct medical care and efforts to improve the quality of care. Insurers selling to large groups (usually 51 or more employees) must spend 85 percent (85%) of premiums on care and quality improvement.

Early Retiree Reinsurance Program

The Early Retiree Reimbursement Program (ERRP) provides reimbursement to participating employment-based plans for a portion of the costs of health benefits for early retirees and their spouses, surviving spouses, and dependents. For the most current information on ERRP news, updates, regulations, and payment processing, please visit their website at www.errp.gov.

Note: Self-funded employers are responsible for the medical claims of covered employees. In a self-funded arrangement, the Health Plan only administers the benefits and is not financially responsible for claims.

Health Reform Updates