Learn More About Marketplace

Health Insurance Marketplace

If you don’t qualify for Medicaid or Medicare, you may qualify for financial assistance to help pay for health care coverage through the Health Insurance Marketplace. The Marketplace is a resource where individuals, families, and small businesses can compare health insurance plans for coverage and affordability. You can apply for coverage even if you have been unable to get it in the past.

Community Health Choice offers a range of Gold, Silver and Bronze Marketplace health plans with options for those who prefer to pay for healthcare expenses as they go, and for those who prefer predictable, up-front costs.

Learn more about Community’s Marketplace health plans.

Questions?

Our hours of operation are
8 a.m. – 5 p.m.

Call Us:
Local: 713.295.6704
Toll-Free 1.855.315.5386

Marketplace Plan Benefits

All of our Marketplace plans cover certain preventive medical services at no additional cost, meaning you won’t pay a copay even if you haven’t met your deductible.

See a list of covered benefits.

See a list of benefits we do not cover.

See a list of the drugs we do not cover.

Practitioner and Provider Availability

Community offers broad network, narrow network, and tiered network health plans.

Members of our broad network plans may visit any physician, specialist, or hospital in our Provider Network.

Members of our narrow network health plans (Bronze 16, Silver 19, and Gold 22) may visit any physician, specialist, or facility affiliated with Memorial Hermann, Harris Health System, St. Joseph, and Legacy Clinics.

In our tiered network health plan (Silver 15), your out-of-pocket costs are determined by which tier your doctor and/or facility is in. Using Tier 1 facilities and Providers saves you the most money. Tier Two provides you the option to choose a facility or Provider from our broad network, but you will pay more in out-of-pocket costs. Learn more about our tiered network plan.

Want to see if your Provider, specialist or hospital is in our network? Search our online directory of Network Providers, which is updated daily.

Service Area

Our service area includes 20 counties in Southeast Texas.

Please read the Emergency, After-Hours Care, Non-Network Providers, and Out-Of-Area Services section of your Member Handbook to see how to get coverage when you are outside of our service area.

Utilization Management and Prior Authorization

Community follows guidelines to determine what health care services we cover. This is called utilization management. Get more information on utilization management decisions.

Prior Authorization means a determination by Us that Services proposed to be provided to a Covered Person are Medically Necessary and appropriate.

For Prescription Drugs, Prior Authorization is a confirmation of the dosage, quantity, and duration as appropriate for the Covered Person’s age, diagnosis and gender. For all other Services or procedures, it is a confirmation of medical necessity and appropriateness only. Prior Authorization is not a representation that the Health Care Services are covered or that the patient is a Covered Person.

For a list of services that require prior authorization, please see our Prior Authorization Guide.

Urgent Concurrent Review is a request for services made while the Member is in the process of receiving care. This typically happens while the Member is receiving inpatient care in a hospital or is receiving ongoing outpatient care. The submission of urgent concurrent review requests will be handled by your Provider.
There may be times when a request needs to be reviewed after services have been rendered. This is called a post-service review. The submission of post-service requests will be handled by your Provider.

Filing an Appeal
An adverse determination is a determination made by Community that the healthcare services provided or proposed to be provided to an enrollee are not medically necessary or appropriate or are experimental or investigational. You have the right to appeal an adverse determination. You, your Provider or someone else you choose as your representative may also appeal. Get more information on Appeals.

Potential Network, Service, and Benefit Restrictions

See a list of limitations and exclusions on Covered Services.

Pharmaceutical Management Procedures

The most commonly prescribed drugs, medicines, and medications covered by Us are specified on Our Drug Formulary. The Drug Formulary identifies categories of drugs, medicines or medications by levels. It also indicates Dispensing Limits and any applicable Prior Authorization or Step Therapy requirements. This information is reviewed on a regular basis by a Pharmacy and Therapeutics committee made up of Physicians and Pharmacists. Placement on the Drug Formulary does not guarantee Your Healthcare Practitioner will prescribe that Prescription Drug, medicine or medication for a particular medical or Mental Health condition.

Get more information on our pharmaceutical management procedure.

Community has a preferred drug list, called a formulary, that provides details and level copays for each covered drug. Review the preferred drug list formulary.

This list will tell you:

If the drug is on the formulary
If the drug requires a prior authorization

If the drug you need is non-preferred, you will need to request an exception by contacting Navitus Health Solutions toll-free at 1.866.333.2757.

Pharmaceutical Restrictions

See a list of prescription drugs not covered by Community.

Private Health Information

Our Notice of Privacy Practices is given to you as part of the Health Insurance Portability and Accountability Act (HIPAA). It says how we can use or share your protected health information (PHI) and sensitive personal information (SPI). We review this notice annually and update if needed.

“Protected health information” and “sensitive personal information” (PHI/SPI) is information that identifies a person or patient. This data can be your age, address, e-mail address, and medical facts. It can be about your past, present or future physical or mental health conditions. It also can be about sensitive healthcare services and other personal facts.

It tells you who we can share it with and how we keep it safe. This includes protection of your oral, written and electronic information across the organization. It tells you how to get a copy of or edit your information. It ensures that any oral, written, and electronic information you share with us is confidential and secure.

You can allow or not allow us to share specific details unless needed by law. You have the right to approve or withdraw the use of your information.

For more information about our privacy policies, please read the full Notice of Privacy Practices section of our Member Handbook.

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“Community Health Choice is always there to answer my questions and help me and my family with our medical needs. I truly appreciate and value their customer support and service.”
– Cecily
Member of Community Health Choice