Inova Health System, the largest nonprofit healthcare system in Northern Virginia, has made its network of providers and facilities available to additional Medicaid and, potentially, Medicare members after coming to an agreement with Optima Health, the health insurance provider announced on June 11.

Effective since May 1, the agreement gives Optima members who are enrolled in Medicaid access to Inova hospitals, physician practices, and other facilities, including the region’s lone Level 1 trauma center and Level IV neonatal intensive care unit.

“Inova is delighted to partner with Optima Health to provide Medicaid recipients with convenient, high-quality Inova facilities and providers, plus the benefits of membership in Optima Health,” Inova Vice President of Population Health Karen Berube said in a statement. “…Now, our Northern Virginia community can have the best of both worlds.”

The agreement between Inova and Optima Health also includes Optima’s Medicare members, but the company needs to obtain approval from the Centers for Medicare and Medicaid Services first before it can market its Medicare Advantage Plan in Northern Virginia.

Optima Health Chief Medical Officer Dr. Thomas Lundquist says he anticipates that CMS will approve the provider’s proposal to offer Medicare Advantage in Northern Virginia by the end of the summer.

Optima Health is a service under Sentara Healthcare, a community, not-for-profit healthcare provider based in Norfolk that serves Virginia and North Carolina.

Because Sentara and Inova are both nonprofit healthcare systems, a sense of competition made the two organizations wary of becoming collaborators, but the Virginia General Assembly’s passage of Medicaid expansion in 2018 inspired Optima Health to reevaluate its membership and opened up discussions that resulted in this agreement, according to Lundquist.

“With growing Medicaid expansion and just as the time rolls on, we realized that it makes sense for both not-for-profit organizations serving the Commonwealth to create access for membership at this time,” Lundquist said. “The timing was right.”

Virginia Medicaid provides low and no-cost health coverage to low-income adults, people with disabilities, families, children, and pregnant women.

After years of stalled debates and negotiations, the General Assembly voted on May 30 to expand the state’s Medicaid program as permitted by the federal Affordable Care Act by opening it up to childless adults and raising the income limit for eligibility on people with disabilities and families with children.

Prior to the expansion, Virginia Medicaid was only open to parents with an annual income up to $6,900 and people with disabilities who earn up to $9,700.

Under the expanded program, adults without children or a disability who earn up to $17,237 are now eligible, and the annual income ceiling for parents and people with disabilities was raised to $29,436 and $17,237, respectively, according to DMAS’s Cover Virginia.

A Commonwealth Institute for Fiscal Analysis study determined that almost 400,000 Virginians would be newly eligible for Medicaid once the expansion took effect on Jan. 1 of this year.

According to the Virginia Department of Medical Assistance Services, which oversees the state’s Medicaid program, 290,133 adults, including 100,348 parents, have gotten health coverage due to the expansion as of the enrollment week that ended on June 14.

Projections showed that Virginia will add 375,000 low-income residents to its Medicaid rolls by July 2020, exceeding earlier estimates that 300,000 people would join in the first 18 months of expansion, according to The Washington Post.

The addition of Inova expands the in-network provider base for Optima Health’s 510,000-plus members from about 26,000 specialists, primary care physicians, hospitals, and other providers to more than 28,500, according to Optima.

While open enrollment for residents eligible for Medicaid under Virginia’s expansion does not start until Nov. 1, the window for non-expansion members in Northern Virginia to choose a new healthcare plan for the year started on June 19 and ends on Aug. 31.

Medicare is a national health insurance program open to U.S. citizens and permanent legal residents who are 65 and older or who have a permanent disability. Health plans offered by private companies that contract with Medicare are known as Medicare Advantage Plans.

Lundquist says Optima Health started exploring its options with Medicare Advantage a few years ago when it introduced health maintenance coverage to residents in Virginia’s Hampton Roads area.

With CMS’s approval, Optima would expand its Medicare coverage to Northern Virginia in 2020.

“We believe it's a very important marketplace for the future and for all Virginians,” Lundquist said. “…Inova, being a very well regarded institution, was one that we felt important to have for Northern Virginians that might choose Medicare Advantage Plans with us.”

Editor's note: 

According to Christina Nuckols of the Virginia Department of Medical Assistance Services, while it is true that there is an open enrollment period in November and December for people who want to purchase private insurance on the marketplace, anyone can actually apply for Medicaid year round and they do not need to wait until Nov. 1 to apply. 


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