OptimaFit® Frequently Asked Questions

In honoring our commitment to the Sentara mission to improve health every day, Optima Health will stay in the ACA Exchange and continue to offer Individual plans for 2018. As a result of marketplace changes, we must withdraw from some markets and raise rates in order to stay in the ACA Exchange. While this is not the outcome we had hoped, it will allow us to continue to serve 80% of our existing members and provide an option for another 70,000 Virginians who are losing their current insurance plans. We will continue to serve our existing markets with our employer-based, Medicare and Medicaid plans.

Frequently Asked Questions on Coverage, Premiums, and Transition of Care

We realize you may have questions about your coverage based on these changes. Please see the question and answers below for answers to common questions.

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Coverage Area Questions

Premium Questions

  • I receive a subsidy and the monthly premium amount in my 2019 renewal letter looks higher than it should be… why is that?

    1. Your renewal letter provides only an estimate of the amount you will pay each month in 2019. This estimate is based on current information we have now, including the amount of financial help you received in 2018. It was calculated by subtracting your current 2018 subsidy from your new, 2019 premium. To find out how much financial help you qualify for in 2019 and your new premium amount, update your Marketplace application at www.healthcare.gov. If you are self-employed, you may now qualify for a Small Group employer plan. Be sure to contact your broker or one of our Personal Plan Advisors for guidance in calculating your reportable income. Our Personal Plan Advisors can be reached at 1-866-659-0892.

  • Is there anything I can do to lower my rates?

    You may be eligible for savings. We have had several members who didn’t know that they qualified for subsidies or alternative plans. It is well worth the time to see if you qualify for subsidies and to learn about all of the plans available to you.

    We know that this can be confusing and there are many ways to connect with someone to help you through the process:

    1. If you have an insurance broker, the best thing you can do is to contact them. They can work with you to find the best match for your personal needs.
    2. If you do not have a broker, call us at 1-866-659-0892. You may also email your question to us. Please include your first and last name in an email to members@optimahealth.com
    3. To verify your eligibility and the level of subsidy for which you may qualify, visit the Health Insurance Marketplace at www.healthcare.gov. Here, you can also create an account to apply for coverage with Optima Health, through the Health Insurance Marketplace. You may also shop for our OptimaFit® plans, get quotes, enroll, and renew.
  • What is the deadline?

    You must take action no later than December 15, 2018 if you wish to make changes or choose a new plan for a January 1, 2019 effective date. If you wish to keep your current plan for 2019, you do not have to do anything. You will be automatically renewed into your current or an equivalent plan beginning January 1, 2019. It is best to update your information on www.healthcare.gov because it might help lower your rate. You can also reach out to your broker to talk through options before automatically renewing the plan that is in your letter. If you do not have a broker, call us at 1-866-659-0892.

  • Are there other assistance plans available?

    1. Depending on your income, you may be eligible for Medicaid, the state-federal program for the poor and disabled. Low-income adults, including those without children, will be eligible as long as their income doesn’t exceed 138% of the Federal Poverty Level, or $16,750 for individuals and $28,700 for a family of three, according to current poverty guidelines.

    2. Medicare is a federally funded insurance program available to all citizens when they turn age 65.

Transition of Care

  • I will be covered by a new insurance company in 2019 and I have ongoing treatments – How will this transition be managed?

    After your coverage under the Individual plan ends, your new carrier will be responsible to approve and pay for any ongoing treatments. We will work with our members to facilitate the approval and transition of care.

  • What if I’m in a treatment plan (PT/OT/Chemo/Home Health) when my plan ends on December 31?

    You should work with your doctor to ensure authorizations for treatment plans are transferred to your new health plan.

  • What if I lose Optima Health Individual & Family plan coverage in the middle of receiving treatments for a chronic condition or pregnancy?

    After your coverage under the Individual plan ends, your new carrier will be responsible to approve and pay for any ongoing treatments.