Optima Health Plan health insurance plan with the Plan ID 20507VA1410008. The plan is called OptimaFit Bronze 6250 20% HSA Direct M.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.29% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.71% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
Health Insurance Plan ID | 20507VA1410008 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
Health Insurance Issuer | Optima Health Plan | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 20507VA1410008-03 | ||||||||||||||||||
Provider Network(s) | ['VAN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 20507VA1410008-00 Standard On Exchange Plan - 20507VA1410008-01 |
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Last Plan Update Date | Tue, 16 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period 30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
This plan contracts with birthing centers. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
Covered Services include diagnostic x-ray, lab services, medical supplies, and advanced diagnostic imaging, such as MRIs and CT scans to evaluate and Stabilize a patient with an Emergency Medical Condition. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Includes one pair of standard single vision, bifocal, trifocal, or progressive eyeglass lenses and one frame per benefit period. This Plan only covers a choice of contact lenses or eyeglasses, but not both. The Plan will not cover any additional services after the limits have been reached. Materials must be received from participating providers. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Include commonly prescribed generic drugs. Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Include services and devices that help a member keep, learn or improve skills and functioning for daily living, and other services for people with disabilities in a variety of inpatient and outpatient settings or facilities. Visit limits may apply. See individual therapy limits. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period 100 Visits per Benefit Period. The Plan will not cover any additional services after the limits have been reached. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Include surgery and services received during an inpatient stay that are required to treat medical condition, illness, or injury. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
Include professional services received while receiving covered services in an inpatient hospital. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
Include covered services provided in an inpatient facility or substance use disorder treatment facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Include covered services provided in an office based setting or other outpatient facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Non-Preferred Brand Drugs
Include brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Copayment or Coinsurance applies to services provided in a free-standing ambulatory surgery center or Hospital outpatient surgical facility. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Visit limits may apply. See individual therapy limits. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
Include professional services received while receiving covered services in a free-standing outpatient facility, or a hospital outpatient facility. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Include brand-name drugs and some generic drugs with higher costs than Tier 1 generics that are considered by the Plan to be standard therapy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Prenatal and Postnatal Care
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Applies to Covered Services done during an office visit, including doctor visits in the home and online visits. You will pay an additional Copayment or Coinsurance for outpatient Habilitative and Rehabilitative therapy and services, injectable and infused medications, allergy care, testing and serum, outpatient advanced imaging procedures, and sleep studies done during an office visit. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Private-Duty Nursing
Limit: 16.0 Hours per Benefit Period 16 Hours per Benefit Period. The Plan will not cover any additional services after the limits have been reached. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period 30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period 30 Visits per Benefit Period. Limit applies separately to habilitative and rehabilitative services. The Plan will not cover any additional services after the limits have been reached. Limit does not apply when received as part of hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period Includes one exam per benefit period. The Plan will not cover any additional services after the limits have been reached. Low vision exams are limited to one every 5 years. Exams must be received from participating providers. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | No Charge |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 100.0 Days per Stay Following inpatient Hospital care or in lieu of hospitalization when, in the Plan?s judgment, skilled services are required. Services include up to 100 days per stay. The Plan will not cover any additional services after the limits have been reached. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Specialty Drugs
Include those drugs classified by the Plan as Specialty Drugs and compound prescription medications. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
Include covered services provided in an inpatient facility or substance use disorder treatment facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Include covered services provided in an office based setting or other outpatient facility for the treatment of mental health and substance use disorders. Please refer to the Summary of Benefits and Coverage or plan documents for plan-specific details. |
YES | 20.00% Coinsurance after deductible |
100.00% |
Transplant
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | 20.00% Coinsurance after deductible |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.642904797 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Limited Cost Sharing Plan Variation |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 90% |
Formulary ID | VAF021 |
Formulary URL | URL |
HIOS Product ID | 20507VA141 |
Import Date | 8/16/2022 20:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 20507 |
Issuer Marketplace Marketing Name | Optima Health Plan |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | Yes |
National Network | No |
Network ID | VAN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency Only |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency Only |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 20507VA1410008-03 |
Plan Marketing Name | OptimaFit Bronze 6250 20% HSA Direct M |
Plan Type | HMO |
Plan Variant Marketing Name | OptimaFit Bronze 6250 20% Direct LCS |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $800 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $6,250 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $700 |
SBC Scenario, Having Diabetes, Deductible | $2,100 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 10% |
Service Area ID | VAS001 |
Source Name | SERFF |
Plan ID | 20507VA1410008 |
State Code | VA |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $12500 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6250 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,250 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $12500 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $6250 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $6,250 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14100 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7050 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $14100 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7050 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,050 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
Unique Plan Design | No |
URL for Enrollment Payment | URL |
URL for Summary of Benefits & Coverage | URL |
Wellness Program Offered | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API