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Getting Started

Eligibility

To be eligible for group health insurance, your business must be headquartered in Maine, with most employees in the state. Additionally, the business must have at least one W2 employee working a minimum of 30 hours. To get a quote, contact your broker or our Business Development team at (207) 402-3353 for assistance.  Sole proprietors and groups with only an owner and spouse are not eligible for a group plan, however, they may choose to enroll in an individual on or an off-exchange plan directly through Health Options or CoverME.gov.

Product Offerings: Fully Insured Plans to Self-Funded Options

Health Options offers a variety of products for businesses with one or more full-time employees. Groups with 49 eligible employees or less are eligible for our community-rated small group plans. In addition, we are Maine’s exclusive carrier of Small Business Health Options Program (SHOP) for employers with fewer than 25 full-time employees. SHOP offers reduced-cost plans based on eligibility for small group employers looking for a flexible and affordable health insurance policy. SHOP eligibility requirements may be found here.

Employers with 50 or more eligible employees may choose from an array of fully insured large group plans. We also offer the option to self-fund employee health coverage through our administrative offering, PioneerASO. Large Group employers will be medically underwritten and receive premium rates based on the group’s prior claims experience. Large Groups are also eligible for the PioneerASO Step-up Plan, which allows a fully insured group to ease into the transition to a self-funded plan. We’ll work together on a long-term strategy of building data to support cost-containment and improved outcomes.

Plan Choices and Adjustments

Employers can select and offer multiple fully insured health plans to their employees.

  • Businesses with 1 – 10 employees can offer 2 plan options, with no more than a $3500 spread in deductible.
  • Businesses with 11 – 19 enrolled employees can offer 2 plan options, with no deductible spread limitation.
  • Businesses with 20 or more enrolled employees can offer 3 plan options, with no deductible spread limitation.

If there are enrollee status changes, employers can easily process changes in their Health Options employer portal. Click here for a list of events that qualify employees for a special enrollment period.

Working With Us

How to Contact Business Development

For questions or concerns about group plans, invoicing, or other account issues, Group Administrators can contact their Health Options Account Manager. Account Managers are assigned at the time a group is activated with Health Options and can be reached at (207) 402-3353, or through their direct line.

Payment & Billing

Employer Invoicing

Payments may be made via check, or electronically through the employer portal. Checks should include the Employer Group ID number and sent with the invoice remittance coupon to:

Community Health Options

PO Box 986529

Boston, MA 92298-6529

Electronic payments can be made by logging into the employer portal and visiting the Employer Billing and Payment Portal (EBPP) section.  Simply click “Pay My Bill” in the navigation links and access the billing and payment module.  Note that employee enrollment adjustments will be seen on the proceeding invoice. If there is a credit balance, the credit will be applied to the next invoice.

A 31-day grace period is provided to pay premiums. If a premium has not been paid by the expiration of the grace period, the group health insurance coverage will be terminated with coverage ending on the last day of that month.

As the employer, you would remain responsible for payment of the missed 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. In addition, we will send a notice to each enrolled employee of the group if the employer is not paid by the end of the grace period. 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 Health Options will not pay for any claims past the termination date.

Provider Network

Accessing care outside of Maine

Health Options offers a robust regional network of providers throughout Maine, New Hampshire, and Eastern Massachusetts.  For most of our plans, Health Options provides a national network of providers through our First Health Network. Click here to view our provider directory.

Communications

Member Communications in the Member Portal

Employees have access to a Member portal which surfaces personal health account information, claims, and prior authorization communications.  In order to save on printing and mailing, and to minimize the impact of paper on our environment, the majority of Health Options’ communications are sent electronically.  Employees looking to receive communications in hard copy may do so by contacting Member Services.

Tax Forms

1095 Forms

At the end of January, Health Options will mail 1095 B forms to small group employees who are enrolled in a qualified health plan. These forms are helpful to view when preparing taxes, however, they are not required to submit with a tax filing. Health Options does not send 1095 C forms to employers with groups who have over 50 or more full-time equivalents on average during the prior calendar year.  1095 C forms are provided by the employer. Visit the IRS website for more information on 1095 C reporting and other applicable large employer requirements.

5500 Forms

Health Options will provide the Form 5500 Schedule A for large group employers upon request.  Form 5500 must be filed by any employer that has 100 or more participants in any welfare benefit plan as of the beginning of the plan year.  More information about Form 5500 and Schedule A is available on the IRS website.

Eligibility

To be eligible for group health insurance, your business must be headquartered in Maine, with most employees in the state. Additionally, the business must have at least one W2 employee working a minimum of 30 hours. To get a quote, contact your broker or our Business Development team at (207) 402-3353 for assistance.  Sole proprietors and groups with only an owner and spouse are not eligible for a group plan, however, they may choose to enroll in an individual on or an off-exchange plan directly through Health Options or CoverME.gov.

Product Offerings: Fully Insured Plans to Self-Funded Options

Health Options offers a variety of products for businesses with one or more full-time employees. Groups with 49 eligible employees or less are eligible for our community-rated small group plans. In addition, we are Maine’s exclusive carrier of Small Business Health Options Program (SHOP) for employers with fewer than 25 full-time employees. SHOP offers reduced-cost plans based on eligibility for small group employers looking for a flexible and affordable health insurance policy. SHOP eligibility requirements may be found here.

Employers with 50 or more eligible employees may choose from an array of fully insured large group plans. We also offer the option to self-fund employee health coverage through our administrative offering, PioneerASO. Large Group employers will be medically underwritten and receive premium rates based on the group’s prior claims experience. Large Groups are also eligible for the PioneerASO Step-up Plan, which allows a fully insured group to ease into the transition to a self-funded plan. We’ll work together on a long-term strategy of building data to support cost-containment and improved outcomes.

Plan Choices and Adjustments

Employers can select and offer multiple fully insured health plans to their employees.

  • Businesses with 1 – 10 employees can offer 2 plan options, with no more than a $3500 spread in deductible.
  • Businesses with 11 – 19 enrolled employees can offer 2 plan options, with no deductible spread limitation.
  • Businesses with 20 or more enrolled employees can offer 3 plan options, with no deductible spread limitation.

If there are enrollee status changes, employers can easily process changes in their Health Options employer portal. Click here for a list of events that qualify employees for a special enrollment period.

How to Contact Business Development

For questions or concerns about group plans, invoicing, or other account issues, Group Administrators can contact their Health Options Account Manager. Account Managers are assigned at the time a group is activated with Health Options and can be reached at (207) 402-3353, or through their direct line.

Employer Invoicing

Payments may be made via check, or electronically through the employer portal. Checks should include the Employer Group ID number and sent with the invoice remittance coupon to:

Community Health Options

PO Box 986529

Boston, MA 92298-6529

Electronic payments can be made by logging into the employer portal and visiting the Employer Billing and Payment Portal (EBPP) section.  Simply click “Pay My Bill” in the navigation links and access the billing and payment module.  Note that employee enrollment adjustments will be seen on the proceeding invoice. If there is a credit balance, the credit will be applied to the next invoice.

A 31-day grace period is provided to pay premiums. If a premium has not been paid by the expiration of the grace period, the group health insurance coverage will be terminated with coverage ending on the last day of that month.

As the employer, you would remain responsible for payment of the missed 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. In addition, we will send a notice to each enrolled employee of the group if the employer is not paid by the end of the grace period. 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 Health Options will not pay for any claims past the termination date.

Accessing care outside of Maine

Health Options offers a robust regional network of providers throughout Maine, New Hampshire, and Eastern Massachusetts.  For most of our plans, Health Options provides a national network of providers through our First Health Network. Click here to view our provider directory.

Member Communications in the Member Portal

Employees have access to a Member portal which surfaces personal health account information, claims, and prior authorization communications.  In order to save on printing and mailing, and to minimize the impact of paper on our environment, the majority of Health Options’ communications are sent electronically.  Employees looking to receive communications in hard copy may do so by contacting Member Services.

1095 Forms

At the end of January, Health Options will mail 1095 B forms to small group employees who are enrolled in a qualified health plan. These forms are helpful to view when preparing taxes, however, they are not required to submit with a tax filing. Health Options does not send 1095 C forms to employers with groups who have over 50 or more full-time equivalents on average during the prior calendar year.  1095 C forms are provided by the employer. Visit the IRS website for more information on 1095 C reporting and other applicable large employer requirements.

5500 Forms

Health Options will provide the Form 5500 Schedule A for large group employers upon request.  Form 5500 must be filed by any employer that has 100 or more participants in any welfare benefit plan as of the beginning of the plan year.  More information about Form 5500 and Schedule A is available on the IRS website.

Use this form to add, remove, or change an enrollment of an employee or dependent in a 2023 enrolled plan. 

Use this form to add, remove, or change an enrollment of an employee or dependent in a 2022 enrolled plan. 

Outside of employer Open Enrollment, certain qualifying events, such as marriage, birth, adoption, or employment status change, can qualify group Members for a Special Enrollment Period. Use this guide to learn more.