Optima Health Insurance Review & Complaints (2024)

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Optima Health is a Virginia-based health insurance company offering both individual and group plans. Their policies provide service through the Sentara Healthcare System.

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What is Optima Health?

Optima Health was created in 1984 by Sentara Healthcare, becoming the first HMO program in the Norfolk, Virginia region. Members are served by the large Sentara provider network, which encompasses more than 100 hospitals and medical centers.

Today the plan serves more than 450,000 members throughout the region. They offer a very wide range of quality health insurance plans with HMO, PPO, and HSA options. They also offer Medicare products and are searched for by customers wanting the best overall Medicare company.

Optima’s headquarters is located in Virginia Beach, VA, with medical centers and hospitals located throughout the state.

What Optima Health plans are available?

Optima has an impressively long list of available plans. Their insurance for individuals and family health care plans offer bronze, silver, and gold choices with multiple sub-levels of coverage in each category. The variety of health plans offered by Optima are divided into those that are available on the health insurance coverage marketplace, and those that are not. Due to a large number of slightly different health plan coverage offered, this review will summarize each group of plans.

Optima FIT HMO Plans

There are four of each level quality health care plans under the Optima FIT HMO plan heading for off marketplace choices; bronze, silver, and gold. Of these, there is one bronze, two silver, and one gold plan available on the marketplace. A quick overview shows that the marketplace plans appear to be the same as their off-marketplace counterparts for the most part. It’s important for customers to know the average health insurance cost per month when researching these plans.

The bronze plans start with the highest deductible level at $7,150 individual and $14,300 family for the Bronze 7150. The lowest available deductible within the bronze plans is the Bronze 5000 HSA, which includes a health savings account. Deductibles are $5,000 individual and $10,000 family. Most of the plans offer no coverage for office visits of any kind until the deductible is met, although the 7150 does allow three office visits with a $25 copay before it reverts to the deductible. Coinsurance after deductible varies from 10-30%. The Bronze 6850 plan is the only plan with a prescription copay, starting at $15, while the rest have a range of coinsurance amounts after deductible.

The silver plans offer deductibles as low as $2,000 individual and $4,000 family, with most plans offering a $25 copay for office visits, some of which are only for the first three visits before the deductible applies. The Silver 2000 is the only silver plan which requires the deductible paid before any primary care office visits are covered, and then with a 30% coinsurance. The Silver 4000 is the one choice with no deductible applied to office visits at all. Two of the silver plans have a $150 pharmacy deductible. Tier 1 drugs start at $15, although in some cases the deductible must first be met.

The gold plans have the lowest deductibles, with the lowest being the Gold 600 plan at $600 individual and $1,200 family. Three of the gold plans have $25 or $30 copays for primary care visits, and one – the Gold 2350 HSA – has no coverage at all until the deductible is met. This plan is also the only choice that requires the deductible is met before pharmacy coverage kicks in, likely because it includes a health savings account. The other three gold plans start at a $15 copay for prescription drugs.

Of the available plans, four are offered on the health insurance marketplace. These are the Bronze 6850 30 M, the Silver 2600 25 and Silver 4000 20%, and the Gold 1000 M. None of these options include an HSA.

Optima FIT Select Plans

There are three off-marketplace Optima FIT plans, one at each metallic category, and only gold and bronze health insurance options are offered on the marketplace. The marketplace plans differ from the off marketplace plans.

The Bronze 6000 HSA is the off marketplace option with a $6,000 individual and $12,000 family deductible. There is no coverage for office visits until the deductible is met, after which most services have a 10% coinsurance.

On the marketplace side, the Bronze offering is the 6850 30M Select. It has higher deductibles at $6,850 for individuals and $13,700 for families. Instead of a coinsurance amount after the deductible is met, it has a $30 copay for office visits.

There is only one silver-level Select plan, and it is off the marketplace. The Silver 4000 20% Select has a $4,000 individual deductible and an $8,000 family deductible. Copays are $25 for primary care and $50 for specialists, and the deductible does not apply.

The gold plan offered off the marketplace is the Gold 1400 Select. It has a $1,400 individual deductible and a $2,800 family deductible. Primary care visits are covered with a $30 copay, but specialist, urgent care, and emergency visits are only covered with 20-30% coinsurance amounts after the deductible is met.

On the marketplace, the plan offered is the Gold 1000 M Select. It has a $1,000 individual deductible and $2,000 family, and copays are lower at $25 for a primary care visit and $50 for a specialist. Coinsurance for urgent care and emergency services are also lower, at 10-20% after deductible.

For most of these plans, prescriptions start at a $15 copay, with the Bronze plan offering no coverage until the deductible is met, and then at 10% coinsurance.

Optima FIT CSR (Cost Share Reduction) Plans

All of these plans are available on the marketplace, and they range from deductibles as low as $150 individual and $300 family up to $4,000 individual and $8,000 family. There are eight plans offered, with silver, gold, and platinum levels. Most plans have a copay of $10-$25 for primary care visits; some only offer this coverage level for 3 visits before the deductible applies.

Are Optima rates competitive?

We ran our sample quote based on a single 30-year-old male non-smoker, living in the zip code of the Optima headquarters in Virginia. Our search returned an incredible 21 plan options.

Prices started at $271.96 a month for the Bronze 7150 plan and rose from there. Given the relatively high deductibles and the lack of coverage, until the deductible is met on most plans, we found Optima’s rates to be high. The Fit Gold 1000 plan came out to $464.83 per month for one person.

We are unable to compare these rates directly to our comparison sample in another state, however, based on other rates we have seen in Virginia, Optima’s rates are very much on the high side.

Optima Health Insurance: Seamlessly Transforming Claims Processing

Ease of Filing a Claim

Optima Health insurance offers multiple channels for filing claims, making it convenient for policyholders. You can file a claim online through their website, over the phone with their customer service team, or even via their mobile app. This flexibility allows you to choose the method that best suits your preferences and needs.

Average Claim Processing Time

While specific information about the average claim processing time is not readily available in the provided content, Optima Health’s website promises fast claims handling. This efficiency is particularly noticeable when dealing with healthcare providers within the Sentara network, which is a significant advantage for policyholders.

Customer Feedback on Claim Resolutions and Payouts

The content does not provide direct customer feedback on claim resolutions and payouts. However, the limited information available, such as the low number of complaints filed with the Better Business Bureau and generally positive reviews, suggests that Optima Health may offer satisfactory claim resolutions and payouts to its policyholders.

Optima Health Insurance: Advancing Your Wellness With Tech Innovations

Mobile App Features and Functionality

Optima Health provides a mobile app that offers various features and functionalities to enhance the policyholder experience. While the content does not delve into specific details about the app, it is reasonable to expect that the app includes capabilities such as accessing policy information, submitting claims, finding in-network providers, and managing account settings on the go.

Online Account Management Capabilities

Optima Health’s online account management capabilities likely offer policyholders the ability to access and manage their insurance accounts through a web portal. This may include tasks like viewing policy details, checking claim statuses, making premium payments, and updating personal information.

Online account management is a convenient way for policyholders to stay in control of their insurance.

Digital Tools and Resources

The content does not provide specific information about the digital tools and resources offered by Optima Health. However, insurance companies often provide tools like cost calculators, health and wellness resources, and educational materials to help policyholders make informed decisions about their healthcare.

It’s worth exploring Optima Health’s website and mobile app to discover the full range of digital tools and resources available to policyholders.

Are the financial strength ratings and consumer reviews positive?

Optima has an A rating with the Better Business Bureau (BBB), with only two complaints filed in the past three years. One of the two was closed in the past year. Even for a regional company, that is a low complaint volume.

There are four Yelp reviews for Optima Health, all negative, although one appears to state that their experience has improved over time. The complaints listed seem mainly to be issues with obtaining prescriptions; one states that the customer service was friendly but not helpful.

Overall, the few reviews out there of this company do not contain anything that raises red flags.

What is the bottom line?

Optima has a wide array of plans, which is likely to confuse and overwhelm the average insurance shopper. Their rates appear, based on our previous samples, to be on the high side. There are few negative reviews, however, and service can often balance out high rates. As a result, Virginia health insurance customers may want to consider Optima as their insurance carrier, perhaps with some expert assistance in the selection of the right plan.