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Enrollment

What is COBRA?

COBRA refers to the Consolidated Omnibus Budget Reconciliation Act which was passed in 1986. The law contains several provisions governing former employees, their spouses and dependents, giving them the right to temporary continuation of coverage when coverage is lost due to certain specific events. Employers with 20 or more employees are typically required to offer COBRA coverage to their employees and COBRA is an employer requirement. You can find more answers to your COBRA questions by visiting the Department of Labor website.

Can you assist my group with COBRA administration?

Community Health Options does not offer COBRA Administration. As such, we do not notice employees of their COBRA rights, communicate with them regarding their enrollment, or invoice them for their COBRA premium once they have been terminated from the Employer plan. The Employer Portal does allow for enrolling former employees in COBRA; however you will be responsible for ensuring all applicable employer laws are followed. Once you enroll an employee in COBRA, we include their portion of the premium on your invoice.

What is a broker and do I need one?

An insurance Broker, also referred to as an Agent or Producer, is a person or entity licensed by the state Bureau of Insurance to market and sell insurance products. Any Broker who sells Community Health Options products has been appointed by Community Health Options and is contractually and ethically bound to represent our products fairly and honestly. Brokers can represent a variety of insurance products and carriers and can often help satisfy all of your insurance needs as a business and employer. Generally speaking, a Broker does not cost you anything more than the premiums you pay to Health Options; they are paid commissions by your insurance carrier and no additional amount may be added to your premium unless it is negotiated by you and the Broker in advance of enrolling with Health Options. Whether or not you use a Broker is entirely up to you, but most businesses find the convenience and advice of a Broker to be very beneficial.

How do I make changes to my employee enrollments?

All of our enrolled employer groups can make changes through our Employer Portal.

Payment & Billing

How do I pay my employer invoice?

Payments may be made via check or electronically through your Employer Portal.

If you choose to pay by check, please include your Employer Group ID number on your check and send it, along with the remittance coupon of your invoice, to:

Community Health Options
PO Box 326
Lewiston, ME 04243

If you choose to pay electronically, the Group Billing and Payment Portal (EBPP) is easily accessible from the Group Dashboard of your Employer Portal. You will see “Pay My Bill” in the navigation links on the top of the screen, which opens a new window to access the Billing and Payment module. There, you can access invoices, view your payment history, make payments, and set up autopay. If you have a question about EBPP or how to use the system, please feel free to reach out to your Health Options Account Manager, or contact Business Development at (207) 402-3353.

What happens when I'm late on payments?

We provide a 31-day grace period to pay your premiums. If your premium remains unpaid at the expiration of the grace period, your group health insurance coverage will be terminated, with coverage ending on the last day of the grace period. The group remains responsible for payment of the grace period premium and any other premium due for coverage through the termination date, even if no claims were incurred. All claims incurred after the expiration of the grace period will be denied. We will send a notice to each enrolled employee of the group if the premium is not paid by the end of the grace period by the Employer. That notice will explain to the employee that the group health plan coverage has ended due to non-payment of premium, the date the coverage ended, and that Community Health Options will not pay for any claims past the termination date.

When will I see employee changes on my invoice?

Enrollment changes made after the third calendar day of each month may not be reflected until the next invoice.

Why does my invoice show $0 for the current month?

Our billing system will generate an invoice around the 10th of each month for every employer group. If you are due for renewal next month and your employee’s renewal enrollments are not completed and submitted before the invoice is generated, the system will show no current coverage and bill $0 for the month. The next invoice will bill for two months at the new premium and will capture any enrollment changes made during the renewal.

What happens if I have a credit on my account?

If you have overpaid, we will maintain a credit balance due. If you remain actively enrolled, the credit balance will be applied to your next invoiced amount.

What do I do if I think my invoice is incorrect?

If you feel that there are errors on your invoice, please contact your Account Manager. We do not recommend marking up or correcting your invoice and submitting it to us as there is no guarantee we will see your comments. 

Doctors & Coverage

What is a Primary Care Provider? (PCP)

Members have a responsibility to choose an In-Network Primary Care Provider (PCP) for themselves and any Dependents. Under the Plan, a Member’s healthcare is mainly provided or arranged through our network of PCPs, Specialist Providers, and other Providers. If a Member does not choose a PCP within 90 days of joining the plan, one will be assigned for them.

Provider Network

Does Community Health Options have a provider network outside of Maine?

We have a robust regional network of Providers throughout Maine, New Hampshire, and Eastern Massachusetts. For Group Plans, we also offer a national network of providers through the First Health Network.

Learn more about our network.

Medications

What is the Community Health Options Drug Formulary?

Our Drug Formulary is a list of covered medications and serves as a guide for Members, Providers and other healthcare professionals. Please see the Medications section for more details.

Claims

What is an Explanation of Benefits?

An Explanation of Benefits (EOB) is a statement we will send a Member to explain what medical treatments and/or services were paid for on the Member’s behalf. It will explain the Community Health Options payment, and the Member’s financial responsibility pursuant to the terms of the policy. EOBs are sent to Members upon the completed processing of a medical claim. If you need assistance reading or interpreting your EOB, please contact Member Services.

What is Coordination of Benefits?

Coordination of Benefits (COB) exists when a Member is also covered by another health plan and is designed to determine which plan pays first. Your Health Options plan will coordinate benefits when applicable.

Tax Forms

What do I need to know about 1095 forms?

A 1095 form is a statement sent to individuals to verify that they had qualified health insurance under the Affordable Care Act. There are three types of 1095 forms: A, B, and C. Employers need only worry about forms 1095 B, and 1095 C. A 1095 B form is mailed at tax time to Employees of Small Employers who are enrolled in a qualified health plan through their employer. They do not need to submit the form with their taxes, although tax preparation professionals may wish to see the form before they submit taxes to the IRS. The 1095 B form is provided by the insurance carrier, so any small employer need only advise employees that they will be receiving the form. A 1095 C form is provided to employees by any Applicable Large Employer (having 50 or more Full Time Equivalents on average during the prior calendar year). For more information on 1095 C reporting and other Applicable Large Employer requirements, visit the IRS website.

Eligibility

What are your eligibility guidelines for group plans?

To be eligible as an Employer Group, there must be at least one eligible common law employee who is receiving a W-2, who is not an owner or spouse of an owner and is working a minimum of 30 hours per week. Sole Proprietors and groups composed only of an owner and spouse are not eligible for a group plan and must enroll on the Individual Market. An eligible group must be headquartered in Maine. They cannot have more employees in any other state than they have employed in Maine to be eligible for coverage with Community Health Options.

What is the difference between a Small Group and a Large Group?

Group size is determined by number of Full Time Equivalents (FTEs). An employer with 1 to 49 Full Time Equivalents is considered a Small Group and will be community rated. Any Employer Group with 50 or more Full Time Equivalents during the prior calendar year is considered a Large Group, and will receive premium rates based on the group’s claim experience and will be medically underwritten. Groups with 50 or more FTEs are also considered an Applicable Large Employer (ALE) by the IRS and are subject to specific reporting requirements. Visit the IRS website for more information about ALE reporting requirements.

How do I calculate the number of Full Time Equivalents?

To calculate the number of Full Time Equivalents (FTEs), you need to also consider your part time employees. Part time employees are those who work less than 30 hours per week. Add up the average number of hours worked per week of all part time employees for the previous calendar year, and divide by 30. Take the result and add the average number of full time employees (30 or more hours per week) that you had on payroll during the prior calendar year. This is your number of Full Time Equivalents. If you need assistance with the calculation, please send an email to businessdevelopmentinfo@healthoptions.org or call (207) 402-3353, to request an FTE calculator tool.

How many plans can an employer choose for their employees?

The number and variability of plans you may select for employees to choose from are limited by the number of enrolled employees.

  • 1 – 10 Enrolled Employees: 2 plan options, with no more than a $2500 spread in Deductible
  • 11 – 19 Enrolled Employees: 2 plan options, with no Deductible spread limitation
  • 20 or more Enrolled Employees: 3 plan options, with no Deductible spread limitation

Working With Us

Who do I contact regarding an account service issue?

If you have questions or concerns about your group plan, invoicing, or have employees experiencing unresolved issues, please contact your Health Options Account Manager. If you do not have your Account Manager’s contact information, please call Business Development at (207) 402-3353.

What is COBRA?

COBRA refers to the Consolidated Omnibus Budget Reconciliation Act which was passed in 1986. The law contains several provisions governing former employees, their spouses and dependents, giving them the right to temporary continuation of coverage when coverage is lost due to certain specific events. Employers with 20 or more employees are typically required to offer COBRA coverage to their employees and COBRA is an employer requirement. You can find more answers to your COBRA questions by visiting the Department of Labor website.

Can you assist my group with COBRA administration?

Community Health Options does not offer COBRA Administration. As such, we do not notice employees of their COBRA rights, communicate with them regarding their enrollment, or invoice them for their COBRA premium once they have been terminated from the Employer plan. The Employer Portal does allow for enrolling former employees in COBRA; however you will be responsible for ensuring all applicable employer laws are followed. Once you enroll an employee in COBRA, we include their portion of the premium on your invoice.

What is a broker and do I need one?

An insurance Broker, also referred to as an Agent or Producer, is a person or entity licensed by the state Bureau of Insurance to market and sell insurance products. Any Broker who sells Community Health Options products has been appointed by Community Health Options and is contractually and ethically bound to represent our products fairly and honestly. Brokers can represent a variety of insurance products and carriers and can often help satisfy all of your insurance needs as a business and employer. Generally speaking, a Broker does not cost you anything more than the premiums you pay to Health Options; they are paid commissions by your insurance carrier and no additional amount may be added to your premium unless it is negotiated by you and the Broker in advance of enrolling with Health Options. Whether or not you use a Broker is entirely up to you, but most businesses find the convenience and advice of a Broker to be very beneficial.

How do I make changes to my employee enrollments?

All of our enrolled employer groups can make changes through our Employer Portal.

How do I pay my employer invoice?

Payments may be made via check or electronically through your Employer Portal.

If you choose to pay by check, please include your Employer Group ID number on your check and send it, along with the remittance coupon of your invoice, to:

Community Health Options
PO Box 326
Lewiston, ME 04243

If you choose to pay electronically, the Group Billing and Payment Portal (EBPP) is easily accessible from the Group Dashboard of your Employer Portal. You will see “Pay My Bill” in the navigation links on the top of the screen, which opens a new window to access the Billing and Payment module. There, you can access invoices, view your payment history, make payments, and set up autopay. If you have a question about EBPP or how to use the system, please feel free to reach out to your Health Options Account Manager, or contact Business Development at (207) 402-3353.

What happens when I'm late on payments?

We provide a 31-day grace period to pay your premiums. If your premium remains unpaid at the expiration of the grace period, your group health insurance coverage will be terminated, with coverage ending on the last day of the grace period. The group remains responsible for payment of the grace period premium and any other premium due for coverage through the termination date, even if no claims were incurred. All claims incurred after the expiration of the grace period will be denied. We will send a notice to each enrolled employee of the group if the premium is not paid by the end of the grace period by the Employer. That notice will explain to the employee that the group health plan coverage has ended due to non-payment of premium, the date the coverage ended, and that Community Health Options will not pay for any claims past the termination date.

When will I see employee changes on my invoice?

Enrollment changes made after the third calendar day of each month may not be reflected until the next invoice.

Why does my invoice show $0 for the current month?

Our billing system will generate an invoice around the 10th of each month for every employer group. If you are due for renewal next month and your employee’s renewal enrollments are not completed and submitted before the invoice is generated, the system will show no current coverage and bill $0 for the month. The next invoice will bill for two months at the new premium and will capture any enrollment changes made during the renewal.

What happens if I have a credit on my account?

If you have overpaid, we will maintain a credit balance due. If you remain actively enrolled, the credit balance will be applied to your next invoiced amount.

What do I do if I think my invoice is incorrect?

If you feel that there are errors on your invoice, please contact your Account Manager. We do not recommend marking up or correcting your invoice and submitting it to us as there is no guarantee we will see your comments. 

What is a Primary Care Provider? (PCP)

Members have a responsibility to choose an In-Network Primary Care Provider (PCP) for themselves and any Dependents. Under the Plan, a Member’s healthcare is mainly provided or arranged through our network of PCPs, Specialist Providers, and other Providers. If a Member does not choose a PCP within 90 days of joining the plan, one will be assigned for them.

Does Community Health Options have a provider network outside of Maine?

We have a robust regional network of Providers throughout Maine, New Hampshire, and Eastern Massachusetts. For Group Plans, we also offer a national network of providers through the First Health Network.

Learn more about our network.

What is the Community Health Options Drug Formulary?

Our Drug Formulary is a list of covered medications and serves as a guide for Members, Providers and other healthcare professionals. Please see the Medications section for more details.

What is an Explanation of Benefits?

An Explanation of Benefits (EOB) is a statement we will send a Member to explain what medical treatments and/or services were paid for on the Member’s behalf. It will explain the Community Health Options payment, and the Member’s financial responsibility pursuant to the terms of the policy. EOBs are sent to Members upon the completed processing of a medical claim. If you need assistance reading or interpreting your EOB, please contact Member Services.

What is Coordination of Benefits?

Coordination of Benefits (COB) exists when a Member is also covered by another health plan and is designed to determine which plan pays first. Your Health Options plan will coordinate benefits when applicable.

What do I need to know about 1095 forms?

A 1095 form is a statement sent to individuals to verify that they had qualified health insurance under the Affordable Care Act. There are three types of 1095 forms: A, B, and C. Employers need only worry about forms 1095 B, and 1095 C. A 1095 B form is mailed at tax time to Employees of Small Employers who are enrolled in a qualified health plan through their employer. They do not need to submit the form with their taxes, although tax preparation professionals may wish to see the form before they submit taxes to the IRS. The 1095 B form is provided by the insurance carrier, so any small employer need only advise employees that they will be receiving the form. A 1095 C form is provided to employees by any Applicable Large Employer (having 50 or more Full Time Equivalents on average during the prior calendar year). For more information on 1095 C reporting and other Applicable Large Employer requirements, visit the IRS website.

What are your eligibility guidelines for group plans?

To be eligible as an Employer Group, there must be at least one eligible common law employee who is receiving a W-2, who is not an owner or spouse of an owner and is working a minimum of 30 hours per week. Sole Proprietors and groups composed only of an owner and spouse are not eligible for a group plan and must enroll on the Individual Market. An eligible group must be headquartered in Maine. They cannot have more employees in any other state than they have employed in Maine to be eligible for coverage with Community Health Options.

What is the difference between a Small Group and a Large Group?

Group size is determined by number of Full Time Equivalents (FTEs). An employer with 1 to 49 Full Time Equivalents is considered a Small Group and will be community rated. Any Employer Group with 50 or more Full Time Equivalents during the prior calendar year is considered a Large Group, and will receive premium rates based on the group’s claim experience and will be medically underwritten. Groups with 50 or more FTEs are also considered an Applicable Large Employer (ALE) by the IRS and are subject to specific reporting requirements. Visit the IRS website for more information about ALE reporting requirements.

How do I calculate the number of Full Time Equivalents?

To calculate the number of Full Time Equivalents (FTEs), you need to also consider your part time employees. Part time employees are those who work less than 30 hours per week. Add up the average number of hours worked per week of all part time employees for the previous calendar year, and divide by 30. Take the result and add the average number of full time employees (30 or more hours per week) that you had on payroll during the prior calendar year. This is your number of Full Time Equivalents. If you need assistance with the calculation, please send an email to businessdevelopmentinfo@healthoptions.org or call (207) 402-3353, to request an FTE calculator tool.

How many plans can an employer choose for their employees?

The number and variability of plans you may select for employees to choose from are limited by the number of enrolled employees.

  • 1 – 10 Enrolled Employees: 2 plan options, with no more than a $2500 spread in Deductible
  • 11 – 19 Enrolled Employees: 2 plan options, with no Deductible spread limitation
  • 20 or more Enrolled Employees: 3 plan options, with no Deductible spread limitation

Who do I contact regarding an account service issue?

If you have questions or concerns about your group plan, invoicing, or have employees experiencing unresolved issues, please contact your Health Options Account Manager. If you do not have your Account Manager’s contact information, please call Business Development at (207) 402-3353.

January 2017: Employment Law Updates for 2017

The new year brings new updates to employment laws. Are you aware there are new laws governing overtime rules and compensation? This update provides an overview of the changes and advice on how to address them. Do you also need help navigating through the dos and don’ts of using social media in hiring? This guide provides employers with legal guidelines to using this resource.

March 2017: Foundations of Leadership

You may be a manager, but are you a leader? What is the one thing every good leader does well? Leadership is a choice, not a title or job position, and this webinar is designed to help you think differently about how you lead. We discuss leadership skills and behaviors, and provide tools for leading from any level.

May 2017: How Population Health Helps Employers

Health-related employee absenteeism leads to decreased productivity. A focus on employee wellbeing can help improve employee satisfaction, productivity, and your organization’s bottom line. Please join Community Health Options care managers, Lori Fortier, RN, and Tyler Tyburski, RN, to learn more about Population Health services and how care management services can help your employees.​

June 2016: Building a Wellness Program on a Budget

New wearable and wellness portal technologies, new data, and the human touch can help large and small employers improve the health of their employee populations efficiently and effectively.

Saving Money on Prescription Medications

Prescription costs are a growing concern for both employers and plan Members. In this webinar the presenters will demonstrate a clinically-based, proactive prescription advice tool that can engage employees and lead to savings. This webinar will introduce you to the Rx Savings Solutions' portal and demonstrate a few common pharmacy scenarios that people experience in their lives. The presentation will highlight some techniques employers can use to further engage your employees in actions that ca

August 2017: The Gift of Providing Performance Feedback

Success in leading lies in inspiring people. Whether serving as a talent scout to hire and retain employees, or as a coach to develop and enhance staff performance, leaders need to build strong relationships. David Pease, Director of Human Resources at Bangor Savings Bank, illustrates the importance of feedback in this webinar and helps you move away from the fear of giving feedback to viewing it as one of the greatest gifts you can provide employees to help them reach their potential.

September 2016: The Engaged Patient: Understanding and Participating in Shared Health Decisions

Find out how the principles of shared decision making can help your employees be more empowered healthcare consumers.

Big to Small - Change Management Techniques for a Healthy Workforce

Size doesn’t matter when it comes to assisting employees in grappling with fast-changing workplace demands.

How Great Managers Motivate

In this webinar, participants explored what great managers do to bring out the best in their employees and how they can create a workplace that inspires employees to think and act like business owners.

We've Got to Stop Meeting Like That

Meetings can be a drain and de-motivator to staff and a waste of resources if not properly led. You’ll observe and review practical skills and strategies for running successful and succinct meetings in your organization. We’ll go over the PADS© model that increases your ability to solve problems, capture innovative ideas, and engage employees. We’ll also address strategies to effectively facilitate some challenging participant behaviors.

Rethinking Old Notions of Millennials in the Workplace

Five years ago a discussion started about what millennials were thinking and how employers needed to adjust. New data suggests it’s time to revisit tools for attracting, recruiting, and retaining great employees.

August 2016: How and When to Use FSAs, HRAs & HSAs

As healthcare costs continue to rise, employers are increasingly offering consumer-driven (or high-deductible) health plans to provide more affordable alternatives to their employees. In this environment, it is increasingly important that employers are informed about the various options and how they would integrate into an organization’s employee benefit packages.

Learn How Supervisors Can Help Create a Culture of Well-Being at Work

Transforming your work culture into one that prioritizes mental wellness at work is not just good for your team, it’s good for your business. This webinar will make the business case for cultivating a culture of mental wellness and review how managers – and companies – can help their employees build positive life-skills that support the mental health and well-being of the workforce.

Workplace Drug Use and Testing in a New Era

Learn how new regulations, cultural attitudes, and new treatment perspectives are changing how employers adjust to a shrinking Maine workforce in an era of chemical use and dependency. This webinar will help you understand how you can use new legislation and new treatment approaches to adjust your drug use and testing approaches in 2018 to foster a better business environment and promote a healthier workforce.

Baby Boomers: One Key to the Future of Maine's Workplace

The concept of retirement is changing dramatically for many Baby Boomers (born 1946-64). Rather than withdrawing from the workplace altogether at the traditional retirement age, as many as 3 out of 5 are seeking meaningful work that utilizes their skills and gives them a sense of purpose. The "working retiree" presents a potential short-term solution for Maine employers who are facing an exceptionally tight labor market.

Coinsurance

Coinsurance is a percentage (for example 30%) you pay toward the cost of certain Covered Services. The plan will pay the remaining amount. Unless specified on your Schedule of Benefits, coinsurance begins once you have met your deductible.

Copayments (Copays)

A copayment is a fixed amount (for example, $15) you pay for a covered healthcare service, usually at the time you receive the service. Unless specified on your Schedule of Benefits, the deductible does not have to be met for the application of a copayment. The amount can vary by the type of covered healthcare service. Copayments do not count toward your deductible. Copayments do count toward your out-of-pocket maximum.

Covered Services

Covered services are the goods or services that the plan will help you pay as outlined in the Member materials. Your Member materials include the Member Benefit Agreement, Schedule of Benefits, and Summary of Benefits and Coverage.

Deductible

The deductible is the amount you pay for certain covered services before the plan pays benefits. If your plan covers more than one person, there will be both an individual deductible and a family deductible. Any one Member covered under your policy only needs to meet the individual deductible, while the other Members of your family combine to meet the remainder of the family deductible.

Out-of-Pocket Costs

Out-of-pocket costs are the costs you pay. Maximum out-of-pocket costs are the total of your copays, coinsurance, and deductible payments that you will be expected to pay.

Prescription Drug Formulary

We cover prescription medicines that are proven effective and list these drugs on a “formulary.” Go to HealthOptions.org/Formulary to see our complete formulary.

Primary Care Provider

Your Primary Care provider (or PCP) is a family doctor, nurse practitioner, pediatrician or other provider with whom you maintain a long-term relationship. Your PCP is a partner in your healthcare who will advise you and provide treatment on a range of health-related issues. He or she may assist you in your interactions with specialists.

Workplace Drug Use and Testing in a New Era

Learn how new regulations, cultural attitudes, and new treatment perspectives are changing how employers adjust to a shrinking Maine workforce in an era of chemical use and dependency. This webinar will help you understand how you can use new legislation and new treatment approaches to adjust your drug use and testing approaches in 2018 to foster a better business environment and promote a healthier workforce.

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Learn How Supervisors Can Help Create a Culture of Well-Being at Work

Transforming your work culture into one that prioritizes mental wellness at work is not just good for your team, it’s good for your business. This webinar will make the business case for cultivating a culture of mental wellness and review how managers – and companies – can help their employees build positive life-skills that support the mental health and well-being of the workforce.

Entering video widget Out of video widget

Saving Money on Prescription Medications

Prescription costs are a growing concern for both employers and plan Members. In this webinar, the presenters will demonstrate a clinically-based, proactive prescription advice tool that can engage employees and lead to savings. This webinar will introduce you to Rx Savings Solutions and demonstrate a few common pharmacy scenarios you might face.

Entering video widget Out of video widget

The Gift of Providing Performance Feedback

Success in leading lies in inspiring people. Whether serving as a talent scout to hire and retain employees, or as a coach to develop and enhance staff performance, leaders need to build strong relationships. David Pease, Director of Human Resources at Bangor Savings Bank, illustrates the importance of feedback in this webinar and helps you move away from the fear of giving feedback to viewing it as one of the greatest gifts you can provide employees to help them reach their potential.

Entering video widget Out of video widget