Welcome New Member
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. We want to make sure you get the most of out of your coverage, that you are treated with respect and that you have access to quality healthcare in your community.
Here is a document that highlights some important resources, such as how to find your Member Handbook, Member Benefit Agreement (MBA) and Summary of Benefits and Coverage (SBC).
If you do not have access to a computer with Internet, you can contact Member Services to request a printed version of your plan documents.
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.
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.
- 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.
Managing Your Auto Pay Plan
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.
Important member information
Understanding how to navigate your health plan can be difficult. We want to make sure you have access to important information about your plan. The following links contain important 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.
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.
Monthly Invoices for Individuals
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 dis-regard it. We do not report late payments to credit agencies. If we do not receive premium payments, plans purchased through the Marketplace will cancel after a three-month grace period and plans purchased directly through Community Health Options will cancel after a one-month grace period.
If you are not sure whether you have canceled your plan through the Marketplace, you should call 1-800-318-2596 to verify.
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.
Information about Form 1099- HC
Massachusetts Health Care Reform law requires that state residents report on their healthcare coverage when filing their state income tax returns. The 1099-HC form, which is a notice from insurance carriers that indicates whether or not a resident and their dependents had Minimum Creditable Coverage in 2015. This form should be included when filing Massachusetts state income tax. Questions about a person’s responsibility to file a 1099-HC form with Massachusetts state income tax return should be directed to a tax advisor or accountant.
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?
- Log in to the secure Member portal
- Click on the blue button that says ASSIGN MY PCP
- Assign a PCP for you and/or your family members by completing the fields on the screen
- Click Submit to confirm your selection
What is prior approval?
What services require 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
- A complete listing of services that require prior approval is available in your Member Benefit Agreement (MBA). You will receive a copy of your MBA with your welcome package.
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.
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.
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.
How do I submit a claim that I paid for out of pocket?
- Medical and prescription reimbursement forms are available on our website: Find a Form.