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Optima Health Insurance Review & Complaints: Health Insurance

Optima Health insurance offerings include individual and family health care plans with bronze, silver, and gold choices called Select Plans. Optima Health rates for a 30-year-old male in Virginia range from $271.96/mo for the Bronze plan to $464.83/mo for the Optima Health gold plan.

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Eric Stauffer is a former insurance agent and banker turned consumer advocate. His priority is to help educate individuals and families about the different types of insurance they need, and assist them in finding the best...

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UPDATED: Sep 9, 2020

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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.

About 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 plans with HMO, PPO, and HSA options. They also offer Medicare products.

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

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Optima Health Plans

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

Optima FIT HMO Plans

There are four each of the bronze, silver, and gold level plans under the Optima FIT HMO plan heading for off marketplace choices. 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.

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 the gold and bronze 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 family. 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 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 specialist, and the deductible does not apply.

The gold plan offered off 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 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.

Optima Rates

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.

Claims

Like all health insurers, Optima handles claims directly with providers. Their website promises fast claims handling, and this is likely especially true of providers within the Sentara network. The website offers little information on claims overall.

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Ratings and Consumer Reviews

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 to be mainly 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.

The Bottom Line

Optima has a dizzying 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, perhaps with some expert assistance in the selection of the right plan.

For a list of companies that we recommend, visit our Best Insurance Companies page.

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Review Information

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About Eric Stauffer

Author: Eric StaufferI am a former insurance agent and banker turned consumer advocate. My priority is to help educate individuals and families about the different types of insurance they need, and assist them in finding the best place to get it.

3 Comments

  1. Optima health prescription plan is a JOKE.

    Tried to get a legal plain prescription for 3 months.

    I finally told them to forget it. Do not contact my doctor again.

    I never received medication from them.

    I will just pay more at my local pharmacy.

    Reply
  2. Optima Health is like having NO insurance at all.

    They paid $180.00 on a $3,000 ER bill.

    Reply
  3. My son went to the ER and had a $6,000 bill.

    After the insurance adjustment, Optima Health only paid $180.00!

    This is like having NO insurance at all.

    Reply

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