Disclaimers for Optima Medicare Plans
Optima Medicare is an HMO with a Medicare contract. Enrollment in Optima Medicare HMO depends on contract renewal.
Optima Medicare Value and Optima Medicare Prime are underwritten by Optima Health Plan.
For more information on Optima Medicare 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 1 - March 31, you can call us 7 days a week from 8 am to 8 pm EST. From April 1 - September 30, 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, premiums and/or 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 Medicare is open to everyone who is eligible for Medicare in the plan service area. Specifically, a person eligible for this plan: 1) is entitled to Medicare benefits under Part A and enrolled in Medicare Part B; 2) must reside in the service area of the Optima Medicare plans; and 3) does not have ESRD. You may be enrolled in only one Medicare prescription drug plan at a time.
By law, Optima Health can refuse to renew its contract with CMS, and CMS also may refuse to renew the contract. Termination or non-renewal may result in termination of the beneficiary’s enrollment in the plans. In addition, the plan may reduce its service area and no longer offer services in the area where the beneficiary resides.
Optima Medicare 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. If this 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.
You may enroll in a Medicare plan only during specific times of the year. To learn more about all of the possible enrollment periods, call Optima Medicare Member Services at the phone numbers provided above. You can also call Medicare toll-free: 1-800-MEDICARE (1-800-633-4227), 24 hours a day. 7 days a week. TTY/TDD users call: 1-877-486-2048. Or visit the website at www.medicare.gov.
Medicare beneficiaries may also enroll in Optima Medicare HMO through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help call:
- 1-800-MEDICARE (1-800-633-4227) or TTY/TDD users call 1-877-486-2048, 24 hours a day/7 days a week;
- The Virginia Department of Medical Assistance Services, (the Virginia Medicaid Office) at 1-800-643-2273. TTY users call 1-800-343-0634; or
- The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 am and 7 pm, Monday through Friday.
Optima Medicare HMO 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 Medicare 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 members.optimahealth.com/medicare or in the Optima Medicare Evidence of Coverage.
You must continue to pay your Medicare Part B premium.
If you need help finding a network provider and/or pharmacy, please call Optima Medicare 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/plans/medicare, or email firstname.lastname@example.org.
All network providers and pharmacies may not be listed in the Optima Medicare 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 Medicare HMO 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 Medicare Member Services at the phone numbers in Disclaimer C.
Last Updated: 9/27/2017