Please Watch the Enrollment Video First
Hi, my name is Lisa Buswell with Optima Health.
I'm a senior client executive and lead Account Manager on the Western Tidewater Regional Jail medical plan. We are excited to continue as the medical carrier for the upcoming plan year. We know we are in some unusual times and would normally be there in person to take you through this presentation instead we're using new tools and technology to make this happen.
Today you'll be listening to Gwen Arnold who will take you through a short presentation that will give you an overview of your 2020 medical plan options and key features. Gwen is a senior client specialist and works with your plan year-round. We have many resources to make sure you have everything you need to get you through your open enrollment period. In addition to today's video we have frequently asked questions and information on how to reach Member Services representatives on the phone and by email.
Thank you for your time. We look forward to serving you in the coming year and we thank you for choosing Optima Health.
Hi, I'm Gwen Arnold the senior client specialist with Optima Health. As Lisa mentioned, these are unusual times and we truly wish we could be there in person to conduct these sessions. However, we've worked extra hard to bring you a great virtual open enrollment experience. Like many we're using new tools and technology to make this happen. We hope you'll take a moment to view the brief video which goes over your upcoming plan options as well as the upcoming plan changes. If you have any questions once you've viewed the video please refer to the frequently asked questions document or feel free to contact our Member Services.
We look forward to a time when we can be there in person and we thank you for choosing Optima Health.
Once you enter the passcode you'll be prompted to watch a 15 minute open enrollment video. If you still have questions check out the frequently asked questions, contact the Member Services phone number or email, or you can reach out to your Human Resources team. We will structure our presentation today to let you learn a little bit more about Optima Health, learn about our large network of doctors and hospitals, learn about your plan choices and the great extras included, and finally we'll go over what you can expect next and where you can find more information if you need it.
- There are no pre-existing condition exclusions on any of your plan options.
- Optima Health has a strong local network and no referrals are required to see a specialist.
- Our After Hours nurse line is available for triage advice or to direct you to the care you may need.
- Your Employee Assistance Program is available to all employees even if you're not enrolled in our plan. We will discuss the EAP program the emergency travel assistance program as well as other features of our plans more in depth later in this presentation.
Now let's go over the local part of our network. Here close to home we have all the major hospital systems in our network, Riverside Health System including the facility and Riverside physicians, all of the Sentara facilities and physicians in the area, Children's Hospital of the Kings Daughters, Bon Secour and more. There are over 33,000 providers in our network across the Commonwealth of Virginia and into northeastern North Carolina. The Optima Health website has an online search tool where you can look up doctors and facilities.
Your Optima Health plans are open access, again this means you do not need a referral to see a specialist. Optima Health encourages but does not require you to select a primary care physician. The Optima Health Network includes a broad network throughout Virginia and beyond Virginia in northeastern North Carolina.
Optima Health uses a national network partner called PHCS. This will be used for dependent children who reside out of area such as those away at college. Your plans are structured so that dependent children residing out of the area will have the in-network level of benefits when seeking care from a provider who participates with PHCS. The PHCS logo will be on the back of the ID card.
With all of your plans, any true emergency situation regardless of the network provider or your location is treated as an in-network event. Your plans will also include emergency travel assistance. This part of your plan covers you when you are traveling more than a hundred miles away from home and need assistance with any unforeseen events on your trip.
Now that you know about the providers in the network let's go over the plans.
Active employees have three plans to choose from. You'll want to review the plan choices to see what's most appealing to you. All benefit plans include in and out of network benefits. Plans include co-payments, deductibles and coinsurance. Remember, a co-payment is a flat predictable dollar amount you pay when you seek care and coinsurance is a percentage of the negotiated rate you pay. A deductible is the amount you pay first before your plan starts to pick up coverage.
Optima Health encourages a PCP selection but does not require it. A PCP relationship is great for routine checkups preventive screenings and for helping you maintain and improve your health. With all of the Optima Health plans you do not need a referral from your PCP to go see a specialist. We will cover these three options briefly and we will go over some of the key features of the plans. The full details of all these plans are found in your summary of benefits hosted on the website where you access this video. Please note that preventive care is covered in full for all of the plan options.
So first we'll talk about the medical benefits and in the next slide we'll cover prescription drug benefits. Let's review the plan options. All plans have a contract your deductible with all plan options there is no in-network deductible your more frequently used services such as doctors visits are covered at a flat affordable co-payments ranging from fifteen to fifty dollars depending on which service you are seeking when you use a service that is listed as a co-payment the deductible does not come into play you just pay the co-payment if you see after deductible then you must pay the deductible first before the plan covers the deductible is on a plan year basis and will reset every July one all plans have an annual out-of-pocket maximum think of this feature as financial protection if all the co-payments and coinsurance you pay in a given year hit this amount the plan begins paying a hundred percent and you do not pay any more. For example, if you are a single person under the POS 25/50 plan, co-payments and coinsurance amounts paid out of pocket hit three thousand. That is the most you would pay for that plan year. Just like the deductible feature, the out of pocket maximum resets each plan year.
Now let's cover prescription drugs. Your prescription benefits include our standard formulary and the formulary is divided into four tiers. Your plans include flat co-payments for your prescription drugs at $15, $40, $75 and 28% with a maximum payment of $200 for tiers 1, 2, 3, and 4 respectively. The mail-order or 90 day supply costs thirty seven fifty one hundred dollars or one eighty seven fifty. Note that 90 day supplies are not available for specialty medications. This is because these drugs often require special handling and more frequent monitoring by your doctor. Here are some important things to remember visit www.optimahealth.com to check which tiers your drugs are on. If the cost of the drug is less than the co-payment you will only pay the cost of the drug. Mail-order provides a convenient way to save money. Optima Health uses OptumRX for mail-order so if you see this name you'll know that this is part of your Optima Health benefits.
So let's talk about how our plans have changed from last year. For 2020, infertility services has been added as a core benefit. There are some exclusions and limitations so please refer to your summary of benefit to view those exclusions and limitations. Benefits for the treatment of autism spectrum disorder will change to remove the current age limit of 2 to 10 from the Virginia autism coverage mandate that includes treatment of applied behavioral analysis or ABA up to $35,000 annually. Chemotherapy, chemotherapy drugs, and radiation therapy will be a separate benefit from IV infusion therapy and respiratory inhalation therapy. While the cost shares will be the same chemotherapy services, chemotherapy drugs, and radiation therapy will now require pre-authorization. When an Optima Health plan includes step therapy requirements members and their prescribing physicians will have access to a formal process to request an exception to step therapy requirements. Lastly, risk-reducing medications for women at increased risk of breast cancer and pre-exposure prophylaxis for persons at high risk of HIV acquisition has been added to the affordable care act list of preventive medications.
The virtual consult benefit will be a separate cost share from your primary care physician office visit benefit. That copay is $10. Your plans all include health and wellness features to help you on the road to better health some of those features are virtual office visits which we'll discuss more in detail shortly an Employee Assistance Program which offers three visits for all her presenting issue regardless of whether or not you're enrolled in the plan a treatment cost calculator which will help you protect your out-of-pocket expenses my life my plan wellness programs and services there is a plethora of information out on our website at www.optimahealth.com/mylifemyplan gym network 360 discounts and an emergency travel assistance program that will offer emergency assistance anytime an emergency Rises when you are more than a hundred miles from home the plan also includes a virtual office visits provided through MD live telemedicine services are covered under your plan and can be accessed through your smart phone tablet or computer board-certified physicians can diagnose minor illnesses and can write prescriptions when necessary the cost of this service is a $10 co-payment Optima Health includes my life my plan we have online resources that include a variety of educational videos materials and tools for your health and wellness support included in my life my plan are items such as an interactive digital health assistant it can emulate a like a personal health assessment reminders for preventive screenings a diabetes prevention program an individual self-paced program such as yoga tai chi meditation or smoking cessation included in your plan are valuable discounts for chiropractic acupuncture or massage therapy services provided through American specialty health providers vision discounts through participating I met vision providers and hearing aid discounts provided through epic if you are a current member and have not already done so or if you are new to Optima Health you want to register online at Optima Health comm you will be able to check all aspects of your plan you can find your benefits summaries and important documents you can print ID cards view claims and plan balances find providers and much more you can find more information and can access these valuable tools and resources on our website next you'll want to take us on the go by downloading the Optima Health mobile app our mobile app is easy to use you can access your MD live virtual visit benefit view claims view your ID cards search for prescription drugs or doctors and more.
Optima Health would like to keep you up-to-date on COVID-19 related health news we have created a dedicated landing page for our members with COVID-19 resources please visit OptimaHealth.com/COVID-19 and click on the "for members" tab for the latest information. If you are not making any changes you are not required to log in to pay course keep in mind that an out-of-area dependent form is required to be updated annually for those members enrolled in our point-of-service plans if you are making changes to your enrollment please log in to pay Corps and update your enrollment to reflect the changes all updates and pay Corps must be entered no later than June 15 now that you viewed our short presentation you might still have some questions we encourage you to check out the FAQ s we've prepared or to reach out to Optima Health member service team to help you thank you for choosing Optima Health you'll have plenty of resources to help you through your enrollment and decision period here at Optima Health you can call us even before you're a member and we will help you understand your plan options and answer any questions you might have you can email us at members at Optima Health com if you decide to send an email be sure to mention the name of your employer so we can be sure to help you with your specific benefits information if you have questions about who can enroll when you can enroll or how those questions can be directed to your employer.
Download our FAQs or these other helpful resources:
Still Have Questions?
Call member services at 1-877-552-7401 or TTY 711.