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.  For a guide to using the online payment system, click here.

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

  • For debit or credit card payments, please have your member identification number and debit or credit 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.

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, or charged to your credit or debit card.  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.

Surprise Billing

What is a surprise bill?

A bill for covered services rendered by an out-of-network provider at an in-network facility, during a service or procedure performed by a network provider, or during a service or procedure previously approved by Health Options and the Member did not knowingly elect to obtain such services from that out-of-network provider.

Which surprise bills are eligible for the Independent Dispute Resolution (IDR) process?

  1. Surprise bills for emergency service
  2. Any other bill for emergency services rendered by an out-of-network provider to a person covered by an insured or self-insured health plan; and
  3. A bill totaling $750 or more received by an uninsured person for emergency health services if the total bill for the single visit is $750 or more regardless of the number of providers included in the bill.

What is the IDR process?

IDR is a process by which a dispute between a provider and health insurer for a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider may be resolved by an Independent Dispute Resolution Entity (IDRE).

The IDR process is initiated by a provider or eligible Member who submits an application. The application is reviewed for eligibility. Within three business days after an application has been determined to be eligible, the IDRE shall assign an arbitrator and notify the patient, the provider or providers, and, if applicable, the carrier or self-insured plan. Additional information may be requested by the arbitrator prior to resolving the dispute.

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 “Doctors & Hospitals.”
  3. Click on ”Find a doctor or hospital.”
  4. Use our provider directory to select your PCP.
  5. Click on the provider's name.
  6. Click on "Select as PCP."
  7. Choose the Member or Members (you and/or a dependent) for whom you're selecting and click "Next."
  8. Click "Confirm."

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?

All Members have access to the Community Health Options Service Area Network--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 the Community Health Options Service Area Network are listed in our find a provider tool.

Medications

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.
  • Download the Express Scripts mobile app to search for cost-savings opportunities.

Why did I pay more for my medication than was 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

Refer to your Member Benefit Agreement for a list of covered services requiring prior approval.

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.
 
All Members have access to the Community Health Options Service Area Network--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.

What is an Explanation of Benefits?

An Explanation of Benefits (EOB) is a statement we will send to 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 at 855-624-6463.

 

 

Tax Forms

What are 1095 Forms?

You may receive one or more forms that provide information about your 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. 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, 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  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.

Transparency 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.  For a guide to using the online payment system, click here.

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

  • For debit or credit card payments, please have your member identification number and debit or credit 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.

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, or charged to your credit or debit card.  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 surprise bill?

A bill for covered services rendered by an out-of-network provider at an in-network facility, during a service or procedure performed by a network provider, or during a service or procedure previously approved by Health Options and the Member did not knowingly elect to obtain such services from that out-of-network provider.

Which surprise bills are eligible for the Independent Dispute Resolution (IDR) process?

  1. Surprise bills for emergency service
  2. Any other bill for emergency services rendered by an out-of-network provider to a person covered by an insured or self-insured health plan; and
  3. A bill totaling $750 or more received by an uninsured person for emergency health services if the total bill for the single visit is $750 or more regardless of the number of providers included in the bill.

What is the IDR process?

IDR is a process by which a dispute between a provider and health insurer for a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider may be resolved by an Independent Dispute Resolution Entity (IDRE).

The IDR process is initiated by a provider or eligible Member who submits an application. The application is reviewed for eligibility. Within three business days after an application has been determined to be eligible, the IDRE shall assign an arbitrator and notify the patient, the provider or providers, and, if applicable, the carrier or self-insured plan. Additional information may be requested by the arbitrator prior to resolving the dispute.

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 “Doctors & Hospitals.”
  3. Click on ”Find a doctor or hospital.”
  4. Use our provider directory to select your PCP.
  5. Click on the provider's name.
  6. Click on "Select as PCP."
  7. Choose the Member or Members (you and/or a dependent) for whom you're selecting and click "Next."
  8. Click "Confirm."

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?

All Members have access to the Community Health Options Service Area Network--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 the Community Health Options Service Area Network are listed in our find a provider tool.

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.
  • Download the Express Scripts mobile app to search for cost-savings opportunities.

Why did I pay more for my medication than was 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

Refer to your Member Benefit Agreement for a list of covered services requiring prior approval.

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.
 
All Members have access to the Community Health Options Service Area Network--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.

What is an Explanation of Benefits?

An Explanation of Benefits (EOB) is a statement we will send to 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 at 855-624-6463.

 

 

What are 1095 Forms?

You may receive one or more forms that provide information about your 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. 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, 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  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.

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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.

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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.

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Retroactive Denials

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

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Enrollee Recoupment of Overpayments

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

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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.

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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.

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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.

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Coordination of Benefits

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

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Use this form to apply for Community Health Options individual, direct-enroll health insurance coverage or to make changes to an existing direct-enroll policy. It’s important to complete all questions and sign this form before submitting your request. If you have any questions, please contact our Member Services team at (855) 624-6463. Note: Members with policies initiated through the Marketplace (HealthCare.gov) must contact the Marketplace to make a change to an existing enrollment.

Use this form to apply for Community Health Options individual, direct-enroll health insurance coverage or to make changes to an existing direct-enroll policy. Members with policies initiated through the Marketplace (HealthCare.gov) must contact the Marketplace to make a change to an existing enrollment. IMPORTANT: Before your request may be processed, all questions must be completed and the application must be signed. If you have any questions, please contact our Member Services team at (855) 624-6463 or your broker.

Your plan allows you to discontinue your Community Health Options coverage during a 10-day “free look period” as described under the terms of the Member Benefit Agreement. Members signed up through the Federally-facilitated Marketplace (Healthcare.gov) must request a termination through the Marketplace, in addition to completing this form.

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

Use this form to give Community Health Options permission to share information about your health plan and related services with others.

Use this form to request consideration of amounts paid for out-of-network covered expenses if your provider is not submitting your claim.

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

Use this form if you disagree with a decision about your benefit and want to file an appeal.

Use this form if you qualify to have your Out-of-Network expenses applied to your In-Network Deductible and Out-of-Pocket Maximum. See form for additional details. 

If you are a small group Member on an HSA plan, you may be eligible for incentives (in the form of gift cards) if you obtain certain services (including PT/OT, radiology, imaging, labs, and infusion therapy) from low-cost, high-quality in-network providers.  Use this form to claim your incentive.

Review this document for a full overview of our 2021 Individual and Family Plans, offered on and off the Marketplace. 

Our Chronic Illness Support Program (CISP) is designed to reduce financial barriers for Members with asthma, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), diabetes, hypertension. Learn more about CISP with this document.

Use this guide to get started with Express Scripts, our pharmacy benefit manager. Express Scripts offers online prescription ordering, auto-generated comparisons, suggestions for lower cost prescription options and home delivery.

Online access to prescription savings and convenience.

Use this guide to learn how to set up and change automatic payment settings for your health insurance premium.

Use this guide to understand your rights and options in the event that a service is denied.