Frequently Asked Questions and Important Questions



Thanks for being a Member! We regard our relationship with you as a vital partnership and want to be a part of improving your health and wellbeing. This page can help you find the information you need about your health plan.  Get answers to frequently asked questions around your benefits, claims, providers, and much more.
 

Enrollment

I enrolled in a 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 card in a safe place and take it with you to all your medical and pharmacy visits. 
 

I signed up for coverage directly through Community Health Options (not through the Health Insurance Marketplace).   Here is what you can expect next:

  • Binding Payment / First Invoice: If you’ve enrolled directly through Community Health Options, we have already received your first, or ‘binding’, premium payment. Thank you! You can expect to receive an invoice mid-month prior to your effective date showing a credit reflecting your payment.
  • ID Cards: 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 ID card in a safe place and take it with you to all your medical and pharmacy visits.  Your card is not valid until the first day of effective coverage listed in this letter.
  • 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.  Visit HealthOptions.org and the Member Login section for instructions on setting up a one-time or automatic withdrawal.
 

I signed up through the Health Insurance Marketplace.  Here’s what you can expect 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.
  • ID Cards: Soon after you receive your first invoice, you will receive a welcome letter with your ID Cards enclosed. Be sure to keep your ID card in a safe place and take it with you to all your medical and pharmacy visits.  Your card is not valid until the first day of effective coverage listed in this letter.
  • 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.  Visit HealthOptions.org and the Member Login section for instructions on setting up a one-time or automatic withdrawal. 
 

Making a Premium Payment

What is a binding payment?  

The binding payment is the first payment made when you enroll.  Your plan will not go into effect unless the binding payment is made prior to the effective date of coverage.
If you have an outstanding premium balance with Community Health Options from coverage effective July 1, 2017 or after, 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. 
 

When will I get my invoice?

Once enrolled, Community Health Options 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 "Online Payment" button.

2. Accessing the automated payment line at (844) 722-6243.
  • For debit card payments, please have your member identification number and debit 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. 
  • Please note: Community Health Options is no longer accepting credit card payments. 
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, and video to show you how to set up, edit, or delete your auto pay plan. Setting up and Managing the Online Payment System
 

Is there a grace period for payment of premiums?

The length of the grace period depends upon whether you receive tax credits. Click HERE for details, and a description of how Health Options handles claims during the grace period.
 

I have received an invoice for the plan I canceled though the Marketplace. How can I stop these? And will this impact my credit score?

  • Community Health Options receives notification from the Marketplace 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 Community Health Options Member Services at (855) 624-6463.
 

PCP Information

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 the blue button that says ASSIGN MY PCP.
  3. Assign a PCP for you and/or your family members by completing the fields on the screen.
  4. Click Submit to confirm your selection.
 

Referrals

Will I need a referral to see a specialist? 

Community Health Options does not require referrals to see Specialists or for specialty care.  We encourage our Members to consult their Primary Care Providers (PCP), however, since coordinating care with a PCP typically results in better health outcomes.
 

Provider Network

Will Community Health Options cover services provided out-of-state? 

Community Health Options Members can take advantage of 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 our network are listed in our find a provider tool.
 

Prior Approval

What is prior approval? 

Some Covered Services require Community Health Options’ 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
Click HERE to learn about the Prior Authorization process.
 

What services require prior approval? 

A complete listing of services that require prior approval is available on the Prior Approval documentation section of the website at (https://www.healthoptions.org/health-care-professionals/professional-document-and-forms/). 
 

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 Community Health Options approves 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.
 
Community Health Options Members can take advantage of 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?

Use the medical and prescription reimbursement forms that are available on our website at Documents and Forms.
 

Can a claim be denied after it is paid?

Yes - a retroactive denial is a reversal of a previously paid claim, through which the enrollee then becomes responsible for the payment. Click HERE to learn about the process for retroactive denials.
 

Prescriptions

A drug I take is not on the Health Options formulary; can I request an exception?

You can request an exception to our formulary; that process is explained here Drug Exception Timeframes and Enrollee Responsibilities.
 

Tax Forms

What are 1095 forms?

 

Other Important Member Information

Understanding how to navigate your health plan can be difficult. We want to make sure you have access to valuable information about your plan. The following links contain information you should know about your plan.

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.

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.  This section explains the claims submission process.

Grace Periods and Claims Pending Policies during the Grace Period
When you purchase coverage under the Plan, you will be billed for the Premium on a monthly basis.  This section describes how Health Options handles claims during the grace period.

Retroactive Denials
A retroactive denial is a reversal of a previously paid claim, through which the enrollee then becomes responsible for the payment.   This section describes the process for retroactive denials.

Enrollee Recoupment of Overpayments
Enrollee recoupment overpayment is the refund of a premium overpayment by the enrollee due to over-billing by the issuer. This section outlines who to contact if you feel you were over-billed.

Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
This section describes the Prior Authorization process through which Health Options approves a request to access a covered benefit before you access the benefit.

Drug Exception Timeframes and Enrollee Responsibilities
This section outlines Community Health Options’ process for allowing exceptions to our formulary.

Information on Explanation of Benefits (EOB)
This section outlines who you should call if you need assistance reading your Explanation of Benefits.

Coordination of Benefits
This section describes coordination of benefits in Maine only and information regarding applicable policies in NH.

 

For answers to additional questions, please contact Community Health Options Member Services Associates at (855) 624-6463.