Before your effective date, which is when your plan begins, you will receive a welcome letter and ID cards. We encourage you to keep your cards in a safe place and take them with you to all your medical and pharmacy visits.
If you did not make your first premium payment when you enrolled, you will receive an invoice mid-month before your effective date. Your health plan will not go into effect unless the first or binding premium payment is made before the effective date of your coverage.
Once enrolled, you will receive an invoice around the 10th business day of every month for the following month, and payment is due on the 1st of the month. Only your first invoice will be delivered via the post office. All invoices after your first are delivered electronically to your portal. If you prefer to receive a paper invoice, please contact our Member Services team.
Monthly premium payments must be made on or before the first of every month to ensure coverage. If you receive a premium tax credit (subsidy) from the Federal Government, you are responsible for paying the balance (after the subsidy has been applied to your total premium amount) to Health Options.
Payment can be made:
A Special Enrollment Period (SEP) is time outside of the annual Open Enrollment that you may be eligible to enroll in health insurance or to change your plan. For example, common qualifying life events could include a new baby, marriage, or becoming a Maine resident. The enrollment window is generally up to 60 days before the qualifying life event through 60 days after it. More information on Special Enrollment Period eligibility can be found at CoverME.gov.
If you believe you have overpaid your monthly health insurance premiums, contact Member Services at (855) 624-6463.
Surprise or balance billing is when out-of-network providers (those who haven’t signed a contract with your health plan directly) unexpectedly bill you for the difference between what your plan agrees to pay and the total amount charged for a service. This can happen when you can’t control who is involved in your care, such as in an emergency or when an out-of-network provider treats you at an in-network facility. This balance owed may not count towards your plan out-of-pocket maximum.
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 practitioner in internal medicine, family practice, general practice, pediatrics, obstetrics and gynecology, or a Physician’s Assistant, a certified registered nurse practitioner or a certified registered nurse-midwife who is authorized to provide Members’ care. Not only does Health Options require you to choose a PCP, but having a strong relationship with a PCP whom you trust is important to maintaining and improving your health.
At this time Health Options does not require a referral to see a specialist, but the specialist may require a referral from your PCP before scheduling an appointment. Please check with your Primary Care Provider (PCP), 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, however, if the service has never been billed to Health Options we will be unable to give an estimate at all.
All providers, including behavioral health providers, in the Health Options Service Area Network are listed in our find a provider tool.
All Members have access to the 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. Our National PPO plans offer in-network coverage with First Health® throughout the country.
Please note: Health Options’ HMO (Health Management Organizations) plans do not include out-of-network benefits.
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:
Under Maine law, if a generic version of your prescribed name-brand medication is available, the pharmacy must dispense the generic unless:
Should you ask the pharmacy to fill your prescription with the name-brand when a generic is available, you will be subject to a Dispense as Written (DAW) penalty. The penalty is the price difference between the name-brand and generic medication you pay when you pick up your prescription. That difference is not applied to the accumulators on your policy. This penalty only occurs if you make this request without your provider requesting it.
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.
In-network Providers will file claims directly with Community Health Options. For a Non-Plan Provider, the Member may need to submit a claim for reimbursement. Click here to learn more about the claims submission process.
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. 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.
You can find our medical and prescription reimbursement forms in the Forms section.
Yes - a retroactive denial is a reversal of a previously paid claim. Click here to learn about the process for retroactive denials.
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.
Interoperability in healthcare is the ability for information, in the form of data, to be shared and used among providers, 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 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 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.
If you believe you have paid too much for your premium and should receive a refund, please call the Member service number on the back of your ID card.
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.