Find answers to your questions

Enrollment

What is COBRA?

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

Can you assist my group with COBRA administration?

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

What is a broker and do I need one?

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

How do I make changes to my employee enrollments?

All of our enrolled employer groups can make changes through our Employer Portal.  Depending on the type of change requested, you may have time restrictions for making the change, or need to include supporting documentation.  Please reference this chart for acceptable forms of documentation and time limits for making specific changes.  A signed Employee Enrollment/Change Form may be submitted in lieu of other documentation for most changes.

Payment & Billing

How do I pay my employer invoice?

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

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

Community Health Options
PO Box 326
Lewiston, ME 04243

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

What happens when I'm late on payments?

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

When will I see employee changes on my invoice?

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

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

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

What happens if I have a credit on my account?

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

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

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

Doctors & Coverage

Why Choose a Primary Care Provider? (PCP)

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

Provider Network

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

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

Learn more about our network.

Medications

What is the Community Health Options Drug Formulary?

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

Claims

What is an Explanation of Benefits?

An Explanation of Benefits (EOB) is a statement we will send 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 is Coordination of Benefits?

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

Tax Forms

What do I need to know about 1095 forms?

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

Eligibility

What are your eligibility guidelines for group plans?

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

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

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

How many plans can an employer choose for their employees?

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

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

Working With Us

Who do I contact regarding an account service issue?

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

What is COBRA?

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

Can you assist my group with COBRA administration?

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

What is a broker and do I need one?

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

How do I make changes to my employee enrollments?

All of our enrolled employer groups can make changes through our Employer Portal.  Depending on the type of change requested, you may have time restrictions for making the change, or need to include supporting documentation.  Please reference this chart for acceptable forms of documentation and time limits for making specific changes.  A signed Employee Enrollment/Change Form may be submitted in lieu of other documentation for most changes.

How do I pay my employer invoice?

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

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

Community Health Options
PO Box 326
Lewiston, ME 04243

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

What happens when I'm late on payments?

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

When will I see employee changes on my invoice?

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

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

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

What happens if I have a credit on my account?

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

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

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

Why Choose a Primary Care Provider? (PCP)

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

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

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

Learn more about our network.

What is the Community Health Options Drug Formulary?

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

What is an Explanation of Benefits?

An Explanation of Benefits (EOB) is a statement we will send 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 is Coordination of Benefits?

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

What do I need to know about 1095 forms?

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

What are your eligibility guidelines for group plans?

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

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

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

How many plans can an employer choose for their employees?

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

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

Who do I contact regarding an account service issue?

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

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.

Information about our commitment to a continuous, company-wide process to ensure the value of our plan offerings, and what that effort entails.