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The most important part of a health plan won’t be found in the Schedule of Benefits

Nov 14, 2023
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Earlier this year, a Community Health Options Member gave birth to a premature baby. Thankfully, the newborn received the best possible care at a big city hospital, but Mom and Dad lived two hours away with two more children to care for, putting incredible strain on the whole family, on top of having a new baby with complex medical needs.

Our care managers began looking for a solution to end the family’s four-hour commute. Once the baby was stabilized and doing well, we worked with the family, the hospital and their pediatrician to move the newborn closer to home, transferring his care to the same pediatrician who would hopefully care for him the rest of his long and healthy childhood.

The move obviously relieved financial strain, but by first considering what was best for the baby and his family, care managers with an intimate knowledge of local resources are helping a baby bond with his family and allowing parents to visit at a hospital close to home, while enjoying dinner and bedtime with their other children. These practices are commonplace for us as we work toward earning a company’s trust to facilitate access to healthcare for their employees and families.

The most important part of a health plan won’t be found on a schedule of benefits, especially in Maine, where people often need help even finding care. The real value lies in having Maine-based care teams who help Members gain access to high-quality providers, including virtual care, and who have on-the-ground knowledge of local resources. That’s critical to employees’ overall well-being, whether they are healthy and simply need screenings to stay that way, or need care to manage chronic illness, behavioral health issues or complex care.

One of the reasons people join Community Health Options is for its commitment to removing barriers to care in ways that drive better health outcomes, with local care managers focused wholly on the patient. So, when plan participants receive a phone call from us, they talk to a clinician who lives in Maine and knows the resources available in their area, and who wants to work with their providers to deliver the care they need, when and where they need it. A great example is our follow-up with every single Member released from the hospital, to ensure their practical needs are met—that they have their prescriptions or a ride to a follow-up appointment, or even have access to meals.

Real care requires finding the best solutions while managing costs. Sometimes claims should be denied, based on national and academic best practices, but even a denied claim may not always be what it seems. Community Health Options recently denied residential behavioral healthcare for a youth because this Member remained in imminent danger of self-harm. Instead, our clinician recommended the Member be evaluated for a higher level of care and medication management.

The same care applies to wellness visits, preventive care or routine care. Beyond managing claims, it’s critical that insurers consider how to remove barriers, beginning with the requirements of providers. For instance, we examined our prior authorization requirements and recently removed hundreds of them for common situations, making life easier for providers and impacting thousands of Members.

That’s the attention we give toward driving collaborative, coordinated care that enhances a plan participant’s experience and improves health outcomes. And that level of care enables a company to form a trusted, long-term partnership with an insurer that can manage costs while investing in the well-being of a company’s employees.

By Dr. Lori Tishler, senior vice president and chief medical officer for Community Health Options, is devoted to providing high-quality, value-based care.


In a recent article we shared upcoming changes in health insurance premiums coming as a result of the merger of the Individual and Small Group health insurance markets in Maine.

This article provides Small Group employers with some additional tips for saving money on healthcare costs, while still providing a very important benefit for employees. As always, we recommend you review these recommendations with your health insurance broker to determine whether these savings tips are right for you and your employees.

Here are five options to consider as your small business looks to manage healthcare costs while offering the best possible benefits to employees: