Home Individuals & Families Resources

Find answers to your questions

Enrollment

I enrolled in a Community Health Options Plan. When will I receive my ID Card?

Soon after you receive your first invoice and prior to your effective date, you will receive a welcome letter with your ID cards enclosed. Be sure to keep your cards in a safe place and take them with you to all your medical and pharmacy visits.

I signed up for coverage through Healthcare.gov. What can I expect to happen next?

Binding Payment / First Invoice: If you did not make your first, or ‘binding,' premium payment at the time of enrollment you will receive an invoice mid-month prior to your effective date. Your health plan will not go into effect unless the first or binding premium payment is made prior to the effective date of coverage. If you have a balance with Community Health Options from coverage within the prior 12 months, this prior balance will be due as part of the Binding Premium Payment. If the full amount due (including the prior balance) is not paid prior to the effective date of coverage, your coverage will not go into effect.

Ongoing Premium Payments / Invoices: Your monthly premium amount needs to be paid on or before the first of every month to ensure you have coverage. If you receive a premium tax credit (subsidy) from the Federal Government, you are responsible to pay the balance (after the subsidy has been applied to your total premium amount) to Community Health Options. You have the following payment options available to you:

  • By mail, with a check or money order, mailed to Community Health Options, P.O. Box 326, Lewiston, ME 04243
  • Through one-time or automatic withdrawals from your bank account (ACH) or with a debit card. Please review the FAQs section titled "Payment & Billing" for more information.

I signed up for coverage directly through Community Health Options (not through Healthcare.gov). What can I expect to happen next?

Binding Payment / First Invoice: If you did not make your first, or ‘binding,' premium payment at the time of enrollment you will receive an invoice mid-month prior to your effective date. Your health plan will not go into effect unless the first or binding premium payment is made prior to the effective date of coverage. If you have a balance with Community Health Options from coverage within the prior 12 months, this prior balance will be due as part of the Binding Premium Payment. If the full amount due (including the prior balance) is not paid prior to the effective date of coverage, your coverage will not go into effect.

Ongoing Premium Payments / Invoices: Your monthly premium amount needs to be paid on or before the first of every month to ensure you have coverage. You have the following payment options available to you:

  • By mail, with a check or money order, mailed to Community Health Options, P.O. Box 326, Lewiston, ME 04243
  • Through one-time or automatic withdrawals from your bank account (ACH) or with a debit card. Please review the FAQs section titled "Payment & Billing" for more information.

How do I know if I qualify for a Special Enrollment Period?

A Special Enrollment Period (SEP) is time outside of the annual Open Enrollment when you can sign up for health insurance if you have experienced a qualifying life event. The enrollment window is generally up to 60 days prior to the qualifying life event through 60 days after it.

The following circumstsances may trigger a Special Enrollment Period:

  1. Loss of other qualifying coverage
  2. Change in Household Size
  3. Changes in Primary Place of Living
  4. Change in Eligibility for Financial Help
  5. Enrollment or Plan Error
  6. Other Qualifying Changes:
    1. Being determined ineligible for Medicaid or CHIP
    2. Exceptional Circumstances
    3. Survivors of Domestic Violence or Abuse or Spousal Abandonment
    4. AmeriCorps Service Member

You may also visit healthcare.gov for more information about the qualifying criteria for a Special Enrollment Period.

Payment & Billing

What is a binding payment?

The binding payment is your first, or 'binding,' premium payment when you first enroll.

When will I get my invoice?

Once enrolled, we will mail you an invoice around the 10th business day of every month for the following month. The payment is due by the first of the month.

How do I make a payment?

Members can make a payment by:

1. Logging into your Member Portal and clicking the "Pay my premium" button. If this is your first time using the Member Portal, click here for a step by step guide. For a guide to using the online payment system, click here.

2. Accessing the automated payment line at (844) 722-6243. 

  • For debit card payments, please have your member identification number and debit card account number, security code and expiration date ready.
  • For payments by check, please have your member identification number, bank routing number and account number ready.

Please note: Community Health Options is no longer accepting credit card payments.

3. Mailing a check to Community Health Options, P.O. Box 326, Lewiston, Maine 04243. Please include your invoice coupon and policy number on the check or money order.

How do I set up, edit, or delete my auto pay plan?

We've put together a quick guide to show you how to set up, edit, or delete your auto pay plan.

You no longer have to write a check to Community Health Options each month to pay your premium – no checks, no stamps, no envelopes, and no worries. You’ll have peace of mind knowing that your monthly premium payment was made automatically, on time, and through a secure method.

How does the program work?  
Once you sign up, your premiums will be deducted automatically from your designated checking or savings account each month.  You will receive an email notification when funds have been deducted. 

Why should I sign up? 
Convenience, security, and peace of mind. You will no longer have to worry about writing a check each month for your premium. You’ll know that your payment was made automatically and on time.

Does Auto Pay cost anything? 
There is no charge to set up or use our automatic payment system.

Can I cancel this service at any time?  
Yes, you may cancel this feature at any time before the last day of the month to affect the following month. 

What happens if I want to make changes?  
You can make changes easily through your auto pay account.

Is there a grace period for payment of premiums?

The length of the grace period depends upon whether you receive tax credits. For details, and a description of how Health Options handles claims during the grace period, please see the FAQ titled Grace Periods and Claims Pending Policies During the Grace Period. You can find it in the Additional Information section of these FAQs.

I have received an invoice for the plan I canceled though Healthcare.gov. How can I stop these? And will this impact my credit score?

We receive notification from the Marketplace (Healthcare.gov) when someone cancels their plan. Sometimes there can be a delay in this notification. Until we receive this notification and process it, we must continue to send invoices.

If you receive an invoice, and you have called the Marketplace to confirm that your plan is canceled, you can disregard it. We do not report late payments to credit agencies.

If we do not receive premium payments, plans that don’t receive an Advanced Premium Tax Credit (APTC) will be canceled after a 31-day grace period. Plans that do receive an APTC will be canceled after a three-month grace period, with a termination date of 31 days after the grace period began.

If you are not sure whether you have canceled your plan through the Marketplace, you should call 1-800-318-2596 to verify.

What can I do if I've been overbilled?

If you believe you have overpaid your monthly health insurance premiums, contact Member Services at (855) 624-6463.

Out-of-Network Liability and Balance Billing
If you receive Covered Services from a Non-Plan Provider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits.  This section describes how Health Options reimburses when a Member receives care from an Out-of-Network provider.

Doctors & Coverage

What is a Primary Care Provider? (PCP)

A provider in internal medicine, family practice, general practice, pediatrics, or obstetrics and gynecology, or a certified nurse practitioner or certified nurse midwife licensed by the Maine Board of Nursing, who is under contract with Community Health Options to provide and authorize Members’ care.

Why do I need a PCP?

Having a strong relationship with a Primary Care Provider (PCP) whom you trust is important to maintaining and improving your health.

How do I select a PCP?

  1. Log in to the secure Member portal.
  2. Click on “Check What’s Covered.”
  3. Click on ”Select a Primary Care Provider.”
  4. Use our provider directory to select your PCP.
  5. Click on “Select My PCP” to complete the process.

Will I need a referral to see a specialist?

It depends on what plan you are enrolled in. Please check with your Primary Care Provider (PCP), however, since coordinating care with a PCP typically results in better health outcomes.

How can I find out how much a procedure will cost?

Our Member Services Associates are unable to provide the cost of any medical service or procedure.  However, the website CompareMaine.org, a product of the Maine Health Data Organization and Maine Quality Forum, will generate the estimated cost of any service or procedure, broken down by county and/or provider.  These estimates are derived from an analysis of actual claims from 32 health insurance plans that have covered procedures in Maine. They are not a guarantee of the true cost to you.

If the CompareMaine.org site does not contain pricing information about the services you are inquiring about, a Member Services Associate can send your inquiry about a specific service or medical code to the appropriate department and Health Options will contact you at a later date with an estimated cost.

Provider Network

Will Community Health Options cover services provided out-of-state?

Community Health Options Members can take advantage of a broad, regional Network of Providers that includes all hospitals in Maine and New Hampshire, select hospitals in Vermont, and certain centers of excellence in Eastern Massachusetts.

Please note: Community Health Options’ HMO (Health Management Organizations) plans do not include out-of-network benefits.

How can I find out if my behavioral health provider is in network?

All providers, including behavioral health providers, in our network are listed in our find a provider tool.

Medications

A drug I take is not on the Health Options formulary; can I request an exception?

You can request an exception to our formulary; that process is explained here: Drug Exception Timeframes and Enrollee Responsibilities.

How can I save money on my prescription medication?

You may be able to save money on your prescription medications by using a few of the following options:

  • If you are taking a brand name medication, speak with your provider about generic alternatives.
  • Ensure your prescriptions are being filled at the lowest cost to you by checking different pharmacy options including Express Scripts mail order pharmacy.
  • Register with Rx Savings Solutions.
  • Download the Express Scripts mobile app to search for cost-savings opportunities.

Why did I paid more for my medication than what applied to my accumulators?

You may have experienced a Dispensed as Written (DAW) penalty. A DAW penalty is applied to your prescription when a brand medication is dispensed and there is a generic alternative available. The DAW penalty is the price difference between the brand and generic medication. The amount you pay will never exceed the cost of the brand, but only a portion of what you pay will be applied to your accumulators. The penalty can be waived if the prescribing provider can demonstrate the medical necessity of the brand medication.

What can I do if my medications are lost or stolen?

We do not cover lost, stolen, spilled, or expired medications. You should contact your provider to discuss available options or call our Member Services Team for assistance.

I did not pay my premium. Can I get my medication?

If you have not paid your premium and are past the 31-day grace period, your pharmacy benefit has been suspended. You can submit payment of your premium, and your pharmacy benefit will be restored once the payment clears (up to three business days). You can also work with your provider to discuss options and alternatives.

How do I obtain medications to accommodate my vacation?

If you are planning to travel within the U.S., you should have your prescription transferred to a pharmacy near your destination. If you are traveling outside of the U.S. contact our Member Services Team for assistance.

How do I submit for reimbursement if I paid cash for my medications?

You should complete the Express Scripts Reimbursement Form.

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.

Prior Approval

What is prior approval?

Some covered services require prior approval before we will pay benefits. The Prior Approval program helps us ensure that:

  • The services you receive are Medically Necessary;
  • You receive the appropriate level of care in the appropriate setting;
  • Information is shared with your Providers so that your care can be coordinated; and
  • We pay the correct amount of Benefits

Claims

How are claims submitted?

Plan Providers will file claims directly with the Plan. Members may need to submit a claim for reimbursement for services from a Non-Plan Provider. Click HERE to learn more about the claims submission process.

How are claims from non-plan (out-of-network) providers treated?

If we approve your claim for payment of services rendered by a Non-Plan Provider, we will pay benefits up to the maximum allowable amount. We will pay benefits directly to you or to the Non-Plan Provider. Click HERE to learn more about out-of-network liability and balance billing.
 
You can take advantage of a broad, regional Network of Providers that includes all hospitals in Maine and New Hampshire, select hospitals in Vermont, and certain centers of excellence in Eastern Massachusetts.

How do I submit a claim that I paid for out of pocket?

You can find our medical and prescription reimbursement forms in the Forms section.

Can a claim be denied after it is paid?

Yes - a retroactive denial is a reversal of a previously paid claim. Click here to learn about the process for retroactive denials.

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.

Tax Forms

What are 1095 Forms?

The Affordable Care Act (ACA) is a federal law that requires almost everyone in the United States to have medical coverage or pay a penalty. Starting in tax year 2015, people who did not have at least a minimal level of coverage may have had to pay a fine to the Internal Revenue Service (IRS).

This year, you may receive one or more forms that provide information about your 2017 health coverage. These forms (similar to a W2) are 1095-A, 1095-B and 1095-C. They contain information that is required for completing your taxes. You are likely to get more than one form if:

  • You had coverage from more than one provider
  • You changed coverage or employers during the year
  • If different members of your family received coverage from different providers

What is the 1095-A form?

Form 1095-A is a tax statement sent to consumers who purchase health insurance directly from the Health Insurance Marketplace at healthcare.gov or a state-based marketplace. This form is mailed by the Marketplace to households where any household member was enrolled in a Marketplace plan during 2017. This form is issued by the Marketplace no later than mid-February.

Please note: On-Exchange Members on a Safe Harbor (a.k.a. Catastrophic) plan will not receive a 1095-A form from the Health Insurance Marketplace. Health Options will send a 1095-B form in mid-February.

Important: You must have your 1095-A before you file your taxes.You will use information from Form 1095-A to fill out IRS Tax Form 8962, when completing your tax filing. This is how you will find out if there’s any difference between the premium tax credit you used and the amount you qualify for. Be sure to carefully read the instructions on Form 1095-A.

If you have questions or concerns about this form, contact the Marketplace at 1-800-318-2596.

Community Health Options is not able to assist you with your 1095-A form.If anyone in your household was covered by a Marketplace plan in 2017, you’ll get Form 1095-A, the Health Insurance Marketplace Statement, from the Health Insurance Marketplace. The 1095-A is sent by the Marketplace, not the IRS or Community Health Options. The 1095-A includes 2017 information for all Marketplace plans held by people in your household, including:

  • Premiums paid
  • Premium tax credits used
  • A figure called ‘second lowest cost silver plan’ or SLCSP

More information on Form 1095-A is available here: https://www.healthcare.gov/tax-form-1095/

If you have questions, do not agree with the information on  your 1095-A, or did not receive a 1095-A and you think you should have, please contact the Marketplace 1-800-318-2596.

What is the 1095-B form?

The 1095-B form is sent to consumers who purchase health insurance directly from a health insurance issuer (like Community Health Options) or who were covered through their employer who purchased insurance directly from a health insurance issuer or the Federal or State Small Business Marketplace. This form is sent by the health insurance issuer and contains information about your health care coverage.

More information on Form 1095-B is available here: https://www.irs.gov/affordable-care-act/individuals-and-families/heres-what-you-need-to-do-with-your-form-1095b.

Call Member Services if:

  • You have received your 1095-B and you believe there is an error
  • If you haven’t received your 1095-B by February 15th

Note that Community Health Options will not have the ability to print copies of the 1095-B forms until we receive the file from our vendor, which we expect will occur in late February at the earliest.

What is the 1095-C form?

Form 1095-C is sent to consumers directly from their employer. Most consumers in a group plan will receive this form depending on the type of insurance provided by their employer.

Questions related to form 1095-C should be directed to your employer.

Additional Information

Out-of-Network Liability and Balance Billing

If you receive Covered Services from a Non-Plan Provider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. If we approve your claim for payment of services rendered by a Non-Plan Provider, we will pay Benefits up to the Maximum allowable amount. Charges above the Maximum allowable amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Plan Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing.

Read more

Enrollee Claims Submission

Plan Providers will file claims directly with the Plan. Members may need to submit a claim for reimbursement for services from a Non-Plan Provider. If you need to submit a claim for a service, you or your Designee must do so within 120 days after the service is rendered. However, you may be allowed extra time if there is good reason why the claim cannot be submitted on time, and if you submit the claim as soon as you reasonably can.

Read more

Grace Periods and Claims Pending Policies During the Grace Period

When you purchase coverage, you pay the Premium on a monthly basis. Premium payments are due the first day of each month for which coverage is provided. For a short period after your monthly premium payment is due, you may make your payment during the grace period and avoid losing your health coverage. No grace period applies to the Binding Premium Payments.

Read more

Retroactive Denials

A retroactive denial is a reversal of a previously paid claim, through which the enrollee then becomes responsible for the payment.

Read more

Enrollee Recoupment of Overpayments

Enrollee recoupment overpayment is the refund of a premium overpayment by the enrollee due to over-billing by the issuer.

Read more

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Prior authorization is a process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.

Read more

Drug Exception Timeframes and Enrollee Responsibilities

We have a process for allowing exceptions to our formulary. To obtain coverage for a drug not on our formulary, you, your Designee, or the prescribing Provider must submit a request to Community Health Options with a clinical rationale for the exception.

Read more

Information on Explanation of Benefits (EOB)

An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy.

Read more

Coordination of Benefits

Coordination of benefits (“COB”) exists when an enrollee is also covered by another plan and determines which plan pays first.

Read more

I enrolled in a Community Health Options Plan. When will I receive my ID Card?

Soon after you receive your first invoice and prior to your effective date, you will receive a welcome letter with your ID cards enclosed. Be sure to keep your cards in a safe place and take them with you to all your medical and pharmacy visits.

I signed up for coverage through Healthcare.gov. What can I expect to happen next?

Binding Payment / First Invoice: If you did not make your first, or ‘binding,' premium payment at the time of enrollment you will receive an invoice mid-month prior to your effective date. Your health plan will not go into effect unless the first or binding premium payment is made prior to the effective date of coverage. If you have a balance with Community Health Options from coverage within the prior 12 months, this prior balance will be due as part of the Binding Premium Payment. If the full amount due (including the prior balance) is not paid prior to the effective date of coverage, your coverage will not go into effect.

Ongoing Premium Payments / Invoices: Your monthly premium amount needs to be paid on or before the first of every month to ensure you have coverage. If you receive a premium tax credit (subsidy) from the Federal Government, you are responsible to pay the balance (after the subsidy has been applied to your total premium amount) to Community Health Options. You have the following payment options available to you:

  • By mail, with a check or money order, mailed to Community Health Options, P.O. Box 326, Lewiston, ME 04243
  • Through one-time or automatic withdrawals from your bank account (ACH) or with a debit card. Please review the FAQs section titled "Payment & Billing" for more information.

I signed up for coverage directly through Community Health Options (not through Healthcare.gov). What can I expect to happen next?

Binding Payment / First Invoice: If you did not make your first, or ‘binding,' premium payment at the time of enrollment you will receive an invoice mid-month prior to your effective date. Your health plan will not go into effect unless the first or binding premium payment is made prior to the effective date of coverage. If you have a balance with Community Health Options from coverage within the prior 12 months, this prior balance will be due as part of the Binding Premium Payment. If the full amount due (including the prior balance) is not paid prior to the effective date of coverage, your coverage will not go into effect.

Ongoing Premium Payments / Invoices: Your monthly premium amount needs to be paid on or before the first of every month to ensure you have coverage. You have the following payment options available to you:

  • By mail, with a check or money order, mailed to Community Health Options, P.O. Box 326, Lewiston, ME 04243
  • Through one-time or automatic withdrawals from your bank account (ACH) or with a debit card. Please review the FAQs section titled "Payment & Billing" for more information.

How do I know if I qualify for a Special Enrollment Period?

A Special Enrollment Period (SEP) is time outside of the annual Open Enrollment when you can sign up for health insurance if you have experienced a qualifying life event. The enrollment window is generally up to 60 days prior to the qualifying life event through 60 days after it.

The following circumstsances may trigger a Special Enrollment Period:

  1. Loss of other qualifying coverage
  2. Change in Household Size
  3. Changes in Primary Place of Living
  4. Change in Eligibility for Financial Help
  5. Enrollment or Plan Error
  6. Other Qualifying Changes:
    1. Being determined ineligible for Medicaid or CHIP
    2. Exceptional Circumstances
    3. Survivors of Domestic Violence or Abuse or Spousal Abandonment
    4. AmeriCorps Service Member

You may also visit healthcare.gov for more information about the qualifying criteria for a Special Enrollment Period.

What is a binding payment?

The binding payment is your first, or 'binding,' premium payment when you first enroll.

When will I get my invoice?

Once enrolled, we will mail you an invoice around the 10th business day of every month for the following month. The payment is due by the first of the month.

How do I make a payment?

Members can make a payment by:

1. Logging into your Member Portal and clicking the "Pay my premium" button. If this is your first time using the Member Portal, click here for a step by step guide. For a guide to using the online payment system, click here.

2. Accessing the automated payment line at (844) 722-6243. 

  • For debit card payments, please have your member identification number and debit card account number, security code and expiration date ready.
  • For payments by check, please have your member identification number, bank routing number and account number ready.

Please note: Community Health Options is no longer accepting credit card payments.

3. Mailing a check to Community Health Options, P.O. Box 326, Lewiston, Maine 04243. Please include your invoice coupon and policy number on the check or money order.

How do I set up, edit, or delete my auto pay plan?

We've put together a quick guide to show you how to set up, edit, or delete your auto pay plan.

You no longer have to write a check to Community Health Options each month to pay your premium – no checks, no stamps, no envelopes, and no worries. You’ll have peace of mind knowing that your monthly premium payment was made automatically, on time, and through a secure method.

How does the program work?  
Once you sign up, your premiums will be deducted automatically from your designated checking or savings account each month.  You will receive an email notification when funds have been deducted. 

Why should I sign up? 
Convenience, security, and peace of mind. You will no longer have to worry about writing a check each month for your premium. You’ll know that your payment was made automatically and on time.

Does Auto Pay cost anything? 
There is no charge to set up or use our automatic payment system.

Can I cancel this service at any time?  
Yes, you may cancel this feature at any time before the last day of the month to affect the following month. 

What happens if I want to make changes?  
You can make changes easily through your auto pay account.

Is there a grace period for payment of premiums?

The length of the grace period depends upon whether you receive tax credits. For details, and a description of how Health Options handles claims during the grace period, please see the FAQ titled Grace Periods and Claims Pending Policies During the Grace Period. You can find it in the Additional Information section of these FAQs.

I have received an invoice for the plan I canceled though Healthcare.gov. How can I stop these? And will this impact my credit score?

We receive notification from the Marketplace (Healthcare.gov) when someone cancels their plan. Sometimes there can be a delay in this notification. Until we receive this notification and process it, we must continue to send invoices.

If you receive an invoice, and you have called the Marketplace to confirm that your plan is canceled, you can disregard it. We do not report late payments to credit agencies.

If we do not receive premium payments, plans that don’t receive an Advanced Premium Tax Credit (APTC) will be canceled after a 31-day grace period. Plans that do receive an APTC will be canceled after a three-month grace period, with a termination date of 31 days after the grace period began.

If you are not sure whether you have canceled your plan through the Marketplace, you should call 1-800-318-2596 to verify.

What can I do if I've been overbilled?

If you believe you have overpaid your monthly health insurance premiums, contact Member Services at (855) 624-6463.

Out-of-Network Liability and Balance Billing
If you receive Covered Services from a Non-Plan Provider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits.  This section describes how Health Options reimburses when a Member receives care from an Out-of-Network provider.

What is a Primary Care Provider? (PCP)

A provider in internal medicine, family practice, general practice, pediatrics, or obstetrics and gynecology, or a certified nurse practitioner or certified nurse midwife licensed by the Maine Board of Nursing, who is under contract with Community Health Options to provide and authorize Members’ care.

Why do I need a PCP?

Having a strong relationship with a Primary Care Provider (PCP) whom you trust is important to maintaining and improving your health.

How do I select a PCP?

  1. Log in to the secure Member portal.
  2. Click on “Check What’s Covered.”
  3. Click on ”Select a Primary Care Provider.”
  4. Use our provider directory to select your PCP.
  5. Click on “Select My PCP” to complete the process.

Will I need a referral to see a specialist?

It depends on what plan you are enrolled in. Please check with your Primary Care Provider (PCP), however, since coordinating care with a PCP typically results in better health outcomes.

How can I find out how much a procedure will cost?

Our Member Services Associates are unable to provide the cost of any medical service or procedure.  However, the website CompareMaine.org, a product of the Maine Health Data Organization and Maine Quality Forum, will generate the estimated cost of any service or procedure, broken down by county and/or provider.  These estimates are derived from an analysis of actual claims from 32 health insurance plans that have covered procedures in Maine. They are not a guarantee of the true cost to you.

If the CompareMaine.org site does not contain pricing information about the services you are inquiring about, a Member Services Associate can send your inquiry about a specific service or medical code to the appropriate department and Health Options will contact you at a later date with an estimated cost.

Will Community Health Options cover services provided out-of-state?

Community Health Options Members can take advantage of a broad, regional Network of Providers that includes all hospitals in Maine and New Hampshire, select hospitals in Vermont, and certain centers of excellence in Eastern Massachusetts.

Please note: Community Health Options’ HMO (Health Management Organizations) plans do not include out-of-network benefits.

How can I find out if my behavioral health provider is in network?

All providers, including behavioral health providers, in our network are listed in our find a provider tool.

A drug I take is not on the Health Options formulary; can I request an exception?

You can request an exception to our formulary; that process is explained here: Drug Exception Timeframes and Enrollee Responsibilities.

How can I save money on my prescription medication?

You may be able to save money on your prescription medications by using a few of the following options:

  • If you are taking a brand name medication, speak with your provider about generic alternatives.
  • Ensure your prescriptions are being filled at the lowest cost to you by checking different pharmacy options including Express Scripts mail order pharmacy.
  • Register with Rx Savings Solutions.
  • Download the Express Scripts mobile app to search for cost-savings opportunities.

Why did I paid more for my medication than what applied to my accumulators?

You may have experienced a Dispensed as Written (DAW) penalty. A DAW penalty is applied to your prescription when a brand medication is dispensed and there is a generic alternative available. The DAW penalty is the price difference between the brand and generic medication. The amount you pay will never exceed the cost of the brand, but only a portion of what you pay will be applied to your accumulators. The penalty can be waived if the prescribing provider can demonstrate the medical necessity of the brand medication.

What can I do if my medications are lost or stolen?

We do not cover lost, stolen, spilled, or expired medications. You should contact your provider to discuss available options or call our Member Services Team for assistance.

I did not pay my premium. Can I get my medication?

If you have not paid your premium and are past the 31-day grace period, your pharmacy benefit has been suspended. You can submit payment of your premium, and your pharmacy benefit will be restored once the payment clears (up to three business days). You can also work with your provider to discuss options and alternatives.

How do I obtain medications to accommodate my vacation?

If you are planning to travel within the U.S., you should have your prescription transferred to a pharmacy near your destination. If you are traveling outside of the U.S. contact our Member Services Team for assistance.

How do I submit for reimbursement if I paid cash for my medications?

You should complete the Express Scripts Reimbursement Form.

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 prior approval?

Some covered services require prior approval before we will pay benefits. The Prior Approval program helps us ensure that:

  • The services you receive are Medically Necessary;
  • You receive the appropriate level of care in the appropriate setting;
  • Information is shared with your Providers so that your care can be coordinated; and
  • We pay the correct amount of Benefits

How are claims submitted?

Plan Providers will file claims directly with the Plan. Members may need to submit a claim for reimbursement for services from a Non-Plan Provider. Click HERE to learn more about the claims submission process.

How are claims from non-plan (out-of-network) providers treated?

If we approve your claim for payment of services rendered by a Non-Plan Provider, we will pay benefits up to the maximum allowable amount. We will pay benefits directly to you or to the Non-Plan Provider. Click HERE to learn more about out-of-network liability and balance billing.
 
You can take advantage of a broad, regional Network of Providers that includes all hospitals in Maine and New Hampshire, select hospitals in Vermont, and certain centers of excellence in Eastern Massachusetts.

How do I submit a claim that I paid for out of pocket?

You can find our medical and prescription reimbursement forms in the Forms section.

Can a claim be denied after it is paid?

Yes - a retroactive denial is a reversal of a previously paid claim. Click here to learn about the process for retroactive denials.

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 are 1095 Forms?

The Affordable Care Act (ACA) is a federal law that requires almost everyone in the United States to have medical coverage or pay a penalty. Starting in tax year 2015, people who did not have at least a minimal level of coverage may have had to pay a fine to the Internal Revenue Service (IRS).

This year, you may receive one or more forms that provide information about your 2017 health coverage. These forms (similar to a W2) are 1095-A, 1095-B and 1095-C. They contain information that is required for completing your taxes. You are likely to get more than one form if:

  • You had coverage from more than one provider
  • You changed coverage or employers during the year
  • If different members of your family received coverage from different providers

What is the 1095-A form?

Form 1095-A is a tax statement sent to consumers who purchase health insurance directly from the Health Insurance Marketplace at healthcare.gov or a state-based marketplace. This form is mailed by the Marketplace to households where any household member was enrolled in a Marketplace plan during 2017. This form is issued by the Marketplace no later than mid-February.

Please note: On-Exchange Members on a Safe Harbor (a.k.a. Catastrophic) plan will not receive a 1095-A form from the Health Insurance Marketplace. Health Options will send a 1095-B form in mid-February.

Important: You must have your 1095-A before you file your taxes.You will use information from Form 1095-A to fill out IRS Tax Form 8962, when completing your tax filing. This is how you will find out if there’s any difference between the premium tax credit you used and the amount you qualify for. Be sure to carefully read the instructions on Form 1095-A.

If you have questions or concerns about this form, contact the Marketplace at 1-800-318-2596.

Community Health Options is not able to assist you with your 1095-A form.If anyone in your household was covered by a Marketplace plan in 2017, you’ll get Form 1095-A, the Health Insurance Marketplace Statement, from the Health Insurance Marketplace. The 1095-A is sent by the Marketplace, not the IRS or Community Health Options. The 1095-A includes 2017 information for all Marketplace plans held by people in your household, including:

  • Premiums paid
  • Premium tax credits used
  • A figure called ‘second lowest cost silver plan’ or SLCSP

More information on Form 1095-A is available here: https://www.healthcare.gov/tax-form-1095/

If you have questions, do not agree with the information on  your 1095-A, or did not receive a 1095-A and you think you should have, please contact the Marketplace 1-800-318-2596.

What is the 1095-B form?

The 1095-B form is sent to consumers who purchase health insurance directly from a health insurance issuer (like Community Health Options) or who were covered through their employer who purchased insurance directly from a health insurance issuer or the Federal or State Small Business Marketplace. This form is sent by the health insurance issuer and contains information about your health care coverage.

More information on Form 1095-B is available here: https://www.irs.gov/affordable-care-act/individuals-and-families/heres-what-you-need-to-do-with-your-form-1095b.

Call Member Services if:

  • You have received your 1095-B and you believe there is an error
  • If you haven’t received your 1095-B by February 15th

Note that Community Health Options will not have the ability to print copies of the 1095-B forms until we receive the file from our vendor, which we expect will occur in late February at the earliest.

What is the 1095-C form?

Form 1095-C is sent to consumers directly from their employer. Most consumers in a group plan will receive this form depending on the type of insurance provided by their employer.

Questions related to form 1095-C should be directed to your employer.

Out-of-Network Liability and Balance Billing

If you receive Covered Services from a Non-Plan Provider, your cost-sharing will be higher, as described in the Out-of-Network portion of your Schedule of Benefits. It is your responsibility to ensure the Providers you receive services from are in the Health Options Network. If we approve your claim for payment of services rendered by a Non-Plan Provider, we will pay Benefits up to the Maximum allowable amount. Charges above the Maximum allowable amount will not apply to your Out-of-Network cost-sharing and will be your responsibility, if the Non-Plan Provider chooses to bill you. This means you may have financial responsibility greater than the cost-sharing described on your Schedule of Benefits. This is sometimes referred to as Balance Billing.

Read more

Enrollee Claims Submission

Plan Providers will file claims directly with the Plan. Members may need to submit a claim for reimbursement for services from a Non-Plan Provider. If you need to submit a claim for a service, you or your Designee must do so within 120 days after the service is rendered. However, you may be allowed extra time if there is good reason why the claim cannot be submitted on time, and if you submit the claim as soon as you reasonably can.

Read more

Grace Periods and Claims Pending Policies During the Grace Period

When you purchase coverage, you pay the Premium on a monthly basis. Premium payments are due the first day of each month for which coverage is provided. For a short period after your monthly premium payment is due, you may make your payment during the grace period and avoid losing your health coverage. No grace period applies to the Binding Premium Payments.

Read more

Retroactive Denials

A retroactive denial is a reversal of a previously paid claim, through which the enrollee then becomes responsible for the payment.

Read more

Enrollee Recoupment of Overpayments

Enrollee recoupment overpayment is the refund of a premium overpayment by the enrollee due to over-billing by the issuer.

Read more

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities

Medical necessity is used to describe care that is reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Prior authorization is a process through which an issuer approves a request to access a covered benefit before the insured accesses the benefit.

Read more

Drug Exception Timeframes and Enrollee Responsibilities

We have a process for allowing exceptions to our formulary. To obtain coverage for a drug not on our formulary, you, your Designee, or the prescribing Provider must submit a request to Community Health Options with a clinical rationale for the exception.

Read more

Information on Explanation of Benefits (EOB)

An EOB is a statement an issuer sends the enrollee to explain what medical treatments and/or services it paid for on an enrollee’s behalf, the issuer’s payment, and the enrollee’s financial responsibility pursuant to the terms of the policy.

Read more

Coordination of Benefits

Coordination of benefits (“COB”) exists when an enrollee is also covered by another plan and determines which plan pays first.

Read more

Cancellation Form - Maine

For Members seeking to discontinue their Community Health Options coverage. Subscribers seeking to drop a dependent spouse or child from the policy must complete an Individual Enrollment/Change Form. (Note: Members with on exchange coverage may not use this form and must make changes by contacting the Federally Facilitated Marketplace directly at 800-318-2596)

10-Day Look Form

For Members seeking to discontinue their Community Health Options coverage during the “free look period” as described under the terms of the Member Benefit Agreement. Members signed up through the Federally-Facilitated Marketplace (Healthcare.gov) will have to request a termination through the Marketplace in addition to completing this form.

Member Reimbursement Form

Use this form for any reimbursement requests you may have if your provider is not submitting your claim.

Express Scripts Prescription Reimbursement Form

Use this claim form to request reimbursement for covered prescription expenses.

Member Appeal Form

Use this form if you disagree with a decision about your benefit, you may be able to file an appeal.

Protected Health Information (PHI) Form

This form allows you to specify how much or how little private information you’re willing for us to disclose to the intended recipient.

Individual Enrollment Application

Thank you for applying for Community Health Options® individual coverage. All questions need to be completed and the application signed before your request will be processed. If you have any questions, please contact your Broker or call Community Health Options at (855) 624-6463.

2019 Individual Enrollment Application

Thank you for applying for Community Health Options® individual coverage. All questions need to be completed and the application signed before your request will be processed. If you have any questions, please contact your Broker or call Community Health Options at (855) 624-6463.

2018 Plan Brochure

A great resource for individuals and families to learn more about our plans.

2018 Plan Design Grid

This two-sided grid highlights our 2018 Plan Design, including cost-share reductions on Silver plans.

How to Compare Plans Worksheet

A useful tool to help figure out costs when considering a few different plan choices.

Setting Up Your Member Portal

If you have not set up your Member portal, click the link for simple, step-by-step Instructions.

Express Scripts Registration Guide

Online access to prescription savings and convenience.

Understanding Your Medical Benefits

General information about your plan, including where to go for your healthcare.

Wellness Assessment Instructions

Take a step towards better health by completing your wellness assessment today.

Setting up and Managing the Online Payment System

We’ve put together a quick guide, and video to show you how to set up, edit, or delete your auto pay plan.

Spring 2018 Member Orientation slides

Information from the 2018 virtual Member Orientation, including speaker notes, to help you learn about your plan benefits and how to get the most out of your coverage.

Fall 2017 Member Roundtable Slides

Information from the 2017 virtual Member Roundtable, including speaker notes, about the re-enrollment process and 2018 plan and benefit changes.

October 2017 Assister Webinar Slides

Slides from the 2017 Assister Webinar about 2018 plan details and changes.

Preventive Services Guide

We want to support and encourage your efforts to protect and promote you and your family’s greatest asset, your health. Many preventive health care services including screenings, checkups and counseling cost you nothing.

Chronic Illness Support Program

A guide to our Chronic Illness Support Program

Pharmacy Benefits

Filling prescriptions made easy with information on our prescription drug benefits that fit your needs.

Behavioral Health: Our Integrated Approach

Health Options firmly believes in treating the whole person- that includes physical health, mental health, and substance use disorder services.

PPO vs. HMO

Information outlining the basic differences between PPO (Preferred Provider Organization) and HMO (Health Maintenance Organization) plans.

Wellness & Prevention Guide

Information about our wellness program, to help in achieving better health overall.​

Quality Improvement Program

Community Health Options commitment to improvement is ingrained throughout the organization. Health Options has actualized this commitment and focus through a Quality Improvement Program (QIP), which is based on its mission to partner with people, businesses, and health care professionals to provide high-quality healthcare benefits that promote health and wellbeing.

Navigator Webinar

Assister Webinar slides for Open Enrollment 6 - 2019 Plans and Updates

Member Roundtable Slide Deck

Health Options Outreach and Education team takes you through all you need to know about your 2019 health plan. 

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.

Online Authorizations Demonstration

Entering video widget Out of video widget

Health Insurance Explained: Premiums & Copays

Learn how premiums and copays work.

Entering video widget Out of video widget

Health Insurance Explained: Deductibles & Coinsurance

Learn how deductibles and co-insurance works.

Entering video widget Out of video widget

Health Insurance Explained: Maximum Out-of-Pocket

Learn more about your maximum out-of-pocket expenses.

Entering video widget Out of video widget

2018 Member Orientation Webinar

Learn more about your plan benefits and how to get the most out of your coverage​.

Entering video widget Out of video widget

December 2017 Member Roundtable

Watch the most recent virtual Member Roundtable.

Entering video widget Out of video widget

Fall 2017 Assister Webinar

2017 Assister Webinar about 2018 plan details and changes.

Entering video widget Out of video widget

Workplace Drug Use and Testing in a New Era

With substance use rising across the nation and state of Maine, how should employers implement testing programs and cultures of clean workplaces?

Entering video widget Out of video widget

Assistance with Open Enrollment 2019

This Community Health Options Webinar covers any questions you may have about healthcare open enrollment for 2019!

Entering video widget Out of video widget