Optima Community Complete (HMO SNP) is a Coordinated Care Plan with a Medicare contract and a contract with the Virginia Medicaid Program. Enrollment in Optima Community Complete (HMO SNP) depends on contract renewal.
Optima Community Complete is underwritten by Optima Health Plan.
For more information on Optima Community Complete benefits, please call Member Services at: 1-800-927-6048. TTY users can call the Virginia Relay Service at 1-800-828-1140 or 711. From October 1st until March 31st, you can call us 7 days a week from 8 am to 8 pm EST. From April 1st until September 30th, you can call us Monday through Friday from 8 am to 8 pm EST. Outside of these times, our interactive voice response system allows you to obtain information on many topics related to your plan.
If you have questions about Medicare benefits you can always call 1-800-MEDICARE (1-800-633-4227); TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week. You can also visit www.medicare.gov.
Benefits and/or Medicare Part D prescription drug co-payments/coinsurance may change on January 1 each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Optima Community Complete is available to anyone who has both Medical Assistance from the State and Medicare.
Optima Community Complete contracts with CMS are renewed annually and the availability of coverage beyond the end of the current contract year is not guaranteed. Termination or non-renewal of the contract by CMS or Optima Health, as authorized by law, may end your enrollment in the plan. In addition, the plan may reduce its service area and no longer offer services in the area where the beneficiary resides. If either situation occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do it within the time period required. Even if a Medicare plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least ninety (90) days before your coverage will end. The letter will explain your options for coverage in your area.
Optima Community Complete provides reimbursement for all covered benefits as long as they are medically necessary.
Except for emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Optima Community Complete specifically authorizes the use of out-of-network providers, care you receive from an out-of-network provider will not be covered.
Details regarding Complaint, Coverage Decision, and Appeal Processes, including timeframes for filing, can be found on this website (www.optimahealth.com/members/community-complete) or in the Optima Community Complete Evidence of Coverage.
You must continue to pay or have the State pay for your Medicare Part B premium.
If you need help finding a network provider and/or pharmacy, please call Optima Community Complete Member Services at the phone numbers listed in Disclaimer C above. If you would like a Provider/Pharmacy Directory mailed to you, you may call Member Services, request one at our website, www.optimahealth.com/members/community-complete, or email firstname.lastname@example.org.
All network providers and pharmacies may not be listed in the Optima Community Complete Provider and Pharmacy Directory. Inclusion of a provider or pharmacy does not guarantee that the provider or pharmacy is open, at the same location as listed in the online directory, or is included in the network.
Value-added services and products are not plan benefits and are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Optima Community Complete grievance process.
Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.
Documents are available in alternative formats such as large print, audio and braille. For more information contact Optima Community Complete Member Services at the phone numbers in Disclaimer C.
Last Updated: 10/16/2018