Questions? We have answers.
Enrollment
The ACA marketplace, sometimes called the exchange or the Health Insurance Marketplace, is where you can buy health insurance plans for yourself and/or your family. Created by the Affordable Care Act (ACA), and often called Obamacare, it is designed to allow people to more easily compare plans, find out if they qualify for subsidies or Medicaid, and enroll in coverage.
Maine’s marketplace is called CoverME.gov. Marketplace plans are grouped into “metal levels:” Bronze, Silver, Gold and Platinum, which offer different levels of coverage based on your monthly premium and out-of-pocket costs.
Are you a Small Business? You can determine your eligibility to purchase a SHOP plan at CoverME.gov- we are the only carrier in Maine that offers tax credited health insurance coverage for your employees. You can purchase SHOP plans through our store front.
CoverME.gov is Maine's Health Insurance Marketplace. It is where people and small businesses in Maine can shop and buy health plans, along with finding out whether they qualify for MaineCare or financial assistance. Individuals and families can purchase a plan during annual Open Enrollment, Nov.1 through Dec. 15, or when they qualify for a Special Enrollment Period.
About 85% of enrollees qualify for financial savings. Depending on household income, household size and other factors, you could be eligible for:
- Premium tax credits to lower monthly payments
- Other savings to reduce costs when you get care
Our Member Services team is available to answer any questions and find the right plan for your unique needs: (855) 624-6463.
Being an Individual or Group Member depends on how you get your plan:
- Individual Members buy their health insurance for themselves and/or their family on CoverME.gov, through a health insurance website or through a broker, and pay a monthly premium to Community Health Options. This is common for people who are self-employed, freelancers, contractors or who do not have health insurance offered at work.
- Group Members get their health insurance coverage at work from a plan offered by their employer. They may pay for a portion of their premium through a payroll deduction. For details about their plan, Group Members should contact their HR administrator or view their Member portal.
You can only change which health plan you have during specific times:
- Open Enrollment Period: This is the main time each year when you can sign up for or change your health plan. If you’re buying it on your own, you’ll have to sign up once a year, usually beginning in November (Nov. 15-Dec. 15 in Maine). Open Enrollment can vary from state to state.
If you get your insurance at work, your employer will generally schedule a specific open enrollment period.
- Special Enrollment Period (SEP): When your life changes—like starting a new job, having a baby, getting married or divorced, losing other health coverage or moving to a new area, that’s called a “qualifying life event.” In those cases, you can change your insurance or buy a new plan, whether you buy insurance on your own or get it at work.
If you experience a qualifying life event, like getting married/divorced, having a baby, losing other health coverage, or moving to a new area, you may be eligible to change or buy a new plan outside Open Enrollment. This is known as a Special Enrollment Period (SEP).
Individual Members can call our Member Services team at (855) 624-6463 for help with your application, call your broker, or visit CoverME.gov if that’s where you bought your plan.
Group Members should contact their employer’s HR administrator for more information on making changes to your plan.
To view our current coverage options, visit the Explore Plans page to get started. If you are looking for an Individual or Family plan and want to find out if you qualify for financial assistance, visit CoverME.gov and search for Community Health Options to see our plans. Our Member Services team is always here to answer any questions at (855) 624-6463.
For Group Members, please contact your employer’s HR administrator for details on your specific plan option.
Getting started
We’ll mail your Welcome Packet to your address on file two to three business days after you’ve enrolled. If you need care before your card arrives, please call Member Services at (855) 624-6463.
Yes, you can select your preferences for paperless delivery on items like invoices, Prior Approval letters, and Explanation of Benefits under your account settings in the Member portal.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
Note: If you require a change to coverage because of a life event like marriage or divorce, you will need to complete an enrollment change form as part of the Special Enrollment Period.
For changes to your ID card like an address update, birthday or name issue, it will depend on where you got your plan:
- Individual Members: Call Member Services at (855) 624-6463 if you purchased a plan directly from us. For Marketplace plans, visit CoverME.gov to update your account information.
- Group Members: Contact your employer’s HR administrator or broker for assistance.
Member portal
The portal has everything you need to get started with your benefits plan. Setting up your secure, personal Member portal takes just a few minutes and gives you 24/7 online access to your plan benefits and documents.
Here’s how to get started:
- Go to login.healthoptions.org
- Click on First Time User? Sign up for an account below the gray sign-in box
- At the next screen, enter your Member ID number, last name and date of birth
Your Member portal gives you 24/7 online access to your plan benefits and documents. Depending on your specific plan, you can:
- Review your important plan documents
- Track and download claims paperwork
- Print or view your ID card
- Search Providers & Hospitals
- Access information on your medications
- View FAQs, Forms and Member Guides
- Update your profile & settings
- Pay your premium (for Individual plans only)
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
Yes, you can access a variety of important documents directly from your Member portal. Depending on your plan, you can find items like:
- Summary of Benefits and Coverage (SBC): An easy-to-understand summary of the benefits and coverage available under your health plan.
- Schedule of Benefits (SoB): A summary of the services, benefit limits and cost-sharing responsibilities under your health plan.
- Member Guide: For most plans, this guide is your all-in-one place for information on benefits, programs and offerings through Community Health Options
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
Billing
For Individual Members, payments are due by the first of each month. You can pay one of the following ways:
- Pay online via your secure Member portal. Click on the “Pay my premium” button at the top of your dashboard and follow the instructions from there. You can also set up autopay in your Member portal.
- Pay by check or money order. Mail your payment, with your Member ID written on it, to:
Community Health Options
P.O. Box 986529
Boston, MA 02298-6529
- Pay by phone at (844) 722-6243.
For Group Members, your payments are handled via your employer. Typically, you pay through a payroll deduction. Contact your HR administrator for more specific details.
If you are looking for an Individual or Family plan, you may be eligible for tax subsidies and savings on the ACA Marketplace, CoverME.gov. Our Member Services team and qualified account representatives are here to help.
You may also be able to reduce out-of-pocket costs by maximizing your plan benefits, including discounts on your prescriptions and chronic illness care.
If you believe you have overpaid, contact (855) 624-6463 – we're happy to help!
Surprise or balance billing is the difference between a provider’s charge and what an insurance company agrees to pay, usually for out-of-network services with providers or services not covered by your plan. That is, if a provider charges $200 and insurance pays $150, you may get a bill for the remaining $50.
This can happen when you can’t control who is involved in your care, such as in an emergency or when an out-of-network provider treats you at an in-network facility. This balance owed may not count toward your plan out-of-pocket maximum.
If you get a bill you’re not expecting, verify it before paying it. Ensure the provider is out-of-network or that the services are not covered. You can also review your Explanation of Benefits (EOB) to confirm your share of the bill. Our Member Services team can help you understand the bill or help you contest it though Independent Dispute Resolution.
- Surprise bills for emergency service
- Any other bill for emergency services rendered by an out-of-network provider
IDR is a way to settle a dispute between a healthcare provider and a health insurance company. This process can also be used for disputed bills from an out-of-network provider.
When a provider or an eligible Member applies for IDR, the application is first reviewed for eligibility. If eligible, an arbitrator, also known as an Independent Dispute Resolution Entity (IDRE), will be assigned within three business days. The IDRE will notify the applicable parties, and if necessary, the carrier or self-insured plan. The arbitrator may ask for more information before making a decision.
No, your Explanation of Benefits (EOB) is not a bill. An EOB is a summary of how your claim was processed and how we applied insurance benefits to your medical services. It details how much was paid toward the claim, and any remaining balance you owe. Sent after a claim is processed, EOBs help you track expenses, understand your coverage and find any billing mistakes when you get your bill from your provider. If you need assistance reading or interpreting your EOB, please call Member Services: (855) 624-6463.
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 Community Health Options plan will coordinate benefits when applicable.
Providers & Coverage
Search for in-network options via our Provider Directory. To get the most accurate results tied to your specific plan, log into your Member portal account first and select Providers & Hospitals from the left-hand menu. Otherwise, manually enter your plan name via the All Plans button in the top right corner.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
With a network of 48,000+ providers, we do our best with coverage that meets your needs. However, if your preferred doctor is out-of-network, and our Member Services is unable to find in-network coverage, we will connect you with our Care Management team to facilitate a plan and ensure a smooth transition of care.
For many Members on non-HSA plans, saving money on labs and X-rays is easy at one of our many site-of-service locations. When you visit one of the many specific locations in our network, you pay as little as $25 copay for labs and $75 for X-rays. You can find site-of-service locations by visiting our provider directory or by clicking the links below:
Your primary care provider (commonly referred to as a PCP) is your first point of contact for non-emergency healthcare and handles your routine visits and common medical problems. Often, this person is a doctor but could also be a physician's assistant, nurse practitioner, pediatrician, gynecologist or other internal health specialists.
Selecting your PCP is an important and necessary step to setting up your plan with us. You can search and select from the Provider Directory in your Member portal.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
You can easily pick your Primary Care Provider from the Member portal:
- Log in to the secure Member portal
- Click on the My Providers widget on your dashboard
- Under Select a Primary Care Provider, click Change primary care doctor
- Search and select your preferred provider
- Click Add as Primary Care Provider
- Choose the Member or Members (you and/or a dependent) for whom you're selecting and confirm.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
There are two different ways to obtain an estimated cost of medical services provided by in-network providers.
- The first option is to visit your Member portal and use the Cost Estimator Tool where you can compare the costs of many common planned services by entering the name of the procedure/service or a CPT (Current Procedural Terminology) code (You can get the code from your provider). Some covered services require Prior Approval before your health plan will pay benefits. If your provider is in-network, they are responsible for submitting the request for approval prior to the scheduled procedure. If you plan to receive care from an out-of-network provider, we encourage you to contact Member Services at (855) 624-6463 regarding Prior Approval requirements. If this service is billed as a preventive service, eligible individuals may have zero cost-share.
- The second option is to visit the website CompareMaine.org, a product of the Maine Health Data Organization and Maine Quality Forum. It 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.
Yes. Our network has more than 48,000 clinicians, hospitals and pharmacies across Maine, New Hampshire, Massachusetts and Vermont, and includes all of Maine’s hospitals (except Togus VA), most in New Hampshire and all Massachusetts Centers of Excellence.
And beyond Maine, we offer national plans that provider coverage for care across the country through our partnership with First Health®. Benefits are also available at nationwide pharmacies.
We also offer urgent care telehealth via our partnership with Amwell so you can get care from anywhere at $0 for most plans ($67 for HSA plans). Members can also choose virtual primary care through Firefly Health for access to their health care team from anywhere they can access the internet.
Medications
A formulary is a list of prescription medications covered by your health insurance plan. You can search the ACA version right here. It includes:
- Medication names: Generic and brand-name versions of drugs
- Dosage forms: Tablets, capsules, injections, vials, etc.
- Tier status: the cost and coverage of the medication
Your specific plan may have a custom formulary as some plans differ. For the most accurate and up-to-date version of your formulary, we recommend signing into your Member portal.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
If you need a medication not listed on the plan’s formulary (drug list), you may still be able to get coverage. To find out, you or your provider may submit this Medication Prior Authorization Form by faxing it to (877) 251-5896. Community Health Options will consider your prescription through the formulary exception review process. If you require an expedited review in an urgent situation, please call (800) 417-8164.
If the request for your medication is denied, you can file an appeal. You also have the right to an external review. If you feel the request was incorrectly denied, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). Note that we must follow the IRO’s decision even if they uphold the denial. An IRO review may be requested by a Member, Member’s representative or prescribing provider by mailing, calling or electronically submitting the request to the following:
Maine Bureau of Insurance,
34 State House Station,
Augusta, ME 04333,
Phone: 1-800-300-5000,
TTY: 1-888-577-6690,
Web site at: www.maine.gov/pfr/insurance
The timeframe for a standard exception review when a request is denied is 72 hours or two business days, whichever is less, from when we receive the request. The timeframe for expedited exception review requests is 24 hours from when we receive the request.
You may be able to save money on your prescription medications. Our Member Services team is here to help explore your options: (855) 624-6463.
Prior Approval
Prior Approval, also known as Prior Authorization, is a process we use for certain services, medications or procedures under your plan. This process helps us support safe, effective and cost-efficient care for our Members.
Prior Approval ensures that:
- You receive the right care when and where you need it
- Information is shared with your Providers so that your care can be coordinated
- We pay the correct amount of benefits
Learn more about the Prior Approval process in our article, Beyond the red tape: Prior Approval helps get access to the right care.
Finding the right form to get Prior Approval on prescription medication can vary based on your plan. Many Individual Members can use this form via Express Scripts, but please note there are other plans for Group Members that use a different service. It is always best to go directly to your Member portal for forms aligned with your specific plan. Our Member Services team is also here to help – call the number on the back of your Member ID card for assistance.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
In most cases your provider will appeal on your behalf. However, if you are doing it yourself, our Member Services team is here to assist you with the appeal process: (855) 624-6463.
Claims
Once you sign in, your most recent claims appear on your dashboard. You can also select Claims from the left-hand menu to search, filter, download and print all your claims.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
In-network providers file claims directly with us. If you use an out-of-network provider, you may need to submit a reimbursement claim. Click here to learn more about the claims submission process.
If a claim gets denied, you can start an appeal process using the Member Medical/Claim Appeal Form. Our Member Services team is here to help too. Call (855) 624-6463.
Yes, that can happen sometimes. That’s called a retroactive denial, which is a reversal of a previously paid claim. Click here to learn about the process for retroactive denials.
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 find our medical and prescription reimbursement forms in the Forms + Documents section.
Our Care Team
Our Maine-based Member Services team is here and happy to assist you. They can help with a variety of questions you may have, including:
- Questions about your benefits and coverage
- Setting up and navigating through your Member portal
- Enrolling in autopay
- Finding providers and facilities
We also have dedicated Claim Service Associates who are here to help with questions you may have regarding claims.
Again, these are just a few examples of how our Member Services team is here to assist you. If you have questions, please reach out: (855) 624-6463 or via the live chat feature within your Member portal.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
Think of our Care Managers as a case manager assigned to help coordinate your care. From finding resources like a ride home from the hospital to organizing your continuity of care paperwork so you never miss a step, Community Health Options’ Care Managers can help you navigate your most difficult health care issues.
The best part? This service is available to all Members at no added cost. You can access uninterrupted care no matter what you’re facing or what plan you’re on—that’s the Community Health Options way.
Call us at (855) 624-6463 with any questions or concerns.
Virtual Care
For all Members, we offer a variety of virtual care services, including a partnership with Firefly Health for virtual primary care and Amwell for telehealth services on behavioral health and urgent care.
We recommend logging into your Member portal to learn more about the specific offerings tied to your plan.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
Good news—for all Members, we currently offer a partnership with Firefly Health to receive virtual primary care from anywhere! Get details on your specific plan offerings in your Member portal.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.
Yes, you can access virtual care via our partners at Amwell for as low as $0 when on a non-HSA plan. For more details, visit your Member portal and go to the Health & Wellness tab on the left-hand side.
Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.