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.
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:
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:
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 circumstances may trigger a Special Enrollment Period:
You may also visit healthcare.gov for more information about the qualifying criteria for a Special Enrollment Period.
The binding payment is your first, or 'binding', premium payment when you first enroll.
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.
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.
3. Mailing a check to Community Health Options, PO Box 986529, Boston, MA 02298-6529. Please include your invoice coupon and policy number on the check or money order.
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.
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.
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.
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.
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.
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.
Having a strong relationship with a Primary Care Provider (PCP) whom you trust is important to maintaining and improving your health.
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.
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.
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.
All providers, including behavioral health providers, in the Community Health Options Service Area Network are listed in our find a provider tool.
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.
Sometimes you need access to pharmacy drugs that are not listed on the plan’s formulary (drug list). These medications are initially reviewed by Health Options and our pharmacy benefit management company, Express Scripts, Inc® through the formulary exception review process. If you need access to a medication that is not listed on our formulary, you or your provider may submit this Medication Prior Authorization Form by faxing it to (877) 251-5896. If you require an expedited review for an urgent circumstance, please call (800) 417-8164. If the request for your medication is denied, you can file an appeal to overturn the decision. Additionally, you have the right to an external review. If you feel the request was incorrectly denied, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). Note, we must follow the IRO’s decision. An IRO review may be requested by a Member, Member’s representative, or prescribing provider by mailing, calling, or electronically submitting the request to the following:
Maine Bureau of Insurance,
34 State House Station,
Augusta, ME 04333,
Phone: 1-800-300-5000,
TTY: 1-888-577-6690,
Web site at: www.maine.gov/pfr/insurance
For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours or 2 business days, whichever is less, from when we receive the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we receive the request.
You may be able to save money on your prescription medications by using a few of the following options:
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.
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.
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.
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.
You should complete the Express Scripts Reimbursement Form.
Some covered services require prior approval before we will pay benefits. The Prior Approval program helps us ensure that:
Refer to your Member Benefit Agreement for a list of covered services requiring prior approval.
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.
You can find our medical and prescription reimbursement forms in the Forms section.
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 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.
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.
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:
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:
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:
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.
Interoperability in healthcare is the ability for information, in the form of data, to be shared and used among doctors, laboratories, hospitals, pharmacies and the consumer/patient. The goal of sharing healthcare data within the health service industry is to create a more effective and efficient means to provide quality care by enabling quicker and more informed decisions.
It is important for Health Options Members to know that you control your health-related data sharing through health applications, like exercise trackers, which you must choose to connect through your smartphone, tablet, etc. If you choose not to share your access – your information remains private. You turn data sharing on and off via your health and wellness application on your personal device. If you don’t download an app and turn on permission, nothing changes.
If you choose to connect health care provider or commercial health tracking apps, you are placing a copy of your personal health information/data outside of Health Options' systems and data protections. This information includes, but is not limited to, your name, date of birth, health insurance plan information, healthcare providers you have seen, claims made for medical, pharmaceutical and laboratory visits, and other data.
You must contact the organization or business that created your app for information about how they will protect, share, or sell your data. It’s important to remember that not all organizations or individuals are covered by health information protection (HIPAA) regulations. Read more about HIPAA here: https://www.hhs.gov/hipaa/index.html. To learn more about your rights related to online data access, visit the Office of Civil Rights here: https://www.hhs.gov/ocr/index.html and the Federal Trade Commission here: https://www.ftc.gov/tips-advice/competition-guidance/industry-guidance/health-care.
You control your health-related data sharing through health apps, like step and exercise trackers, or through provider office chart applications, which you must choose to connect through your smartphone, tablet, etc. See a list of the healthcare applications here: https://myhealthapplication.com/health-apps/gallery.
If you do choose to share access through your personal devices and want to stop sharing, you must change your preferences on your personal device(s), not at your Member portal or anywhere else on the Community Health Options website.
You must contact the organization or business that created your app to address any inaccuracies in the data displayed by that app. If there are inaccuracies in medical records, billing records, payment and claims records, or enrollment records maintained by Community Health Options, please contact Member Services at (855) 624-6463 for a “Request for Amendment to PHI” form.
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.
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.
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.
A retroactive denial is a reversal of a previously paid claim, through which the enrollee then becomes responsible for the payment.
Enrollee recoupment overpayment is the refund of a premium overpayment by the enrollee due to over-billing by the issuer.
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.
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 Health Options with a clinical rationale for the exception.
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.
Coordination of benefits (“COB”) exists when an enrollee is also covered by another plan and determines which plan pays first.
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 Maine Health Insurance Marketplace (CoverME.gov) must contact the Marketplace to make a change to an existing enrollment.
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.
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 to request a medication that is not listed on the Health Options formulary.
Use this form if you disagree with a decision about your benefit and want to file an appeal.
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 restrictions on how Health Options will use or disclosure your protected health information (PHI) for treatment, payment or health care operations and how your information will be disclosed or not disclosed to family members or others involved in your care.
Use this form to register your complaint about the way Health Options has handled your protected health information (PHI).
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 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 2022 Individual and Family Plans, offered on and off the Marketplace.
Use this guide to look up information about your plan benefits and how to use them to access care.
If you plan to receive a service that requires Prior Approval by an out-of-network provider (if you chose a Plan with out-of-network coverage), you are responsible for ensuring Health Options receives Prior Approval and Notification within the required timeframes.
We regard our relationship with you as a vital partnership and want to play a role in improving your health and wellbeing. Understanding your rights and responsibilities will help you to get the most out of your plan and be your healthiest self.
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 online payment settings for your monthly insurance premiums.
Use this guide to understand your rights and options in the event that a service is denied.