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Transparency in Coverage 2021

Transparency in Coverage 2021

On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (P.L.111-152) was signed into law. The two laws are collectively referred to as the Affordable Care Act. The Affordable Care Act established new competitive private health insurance markets called Marketplaces or Exchanges. By providing a place for one-stop shopping, Marketplaces make purchasing health insurance easier and more transparent, and put greater control and more choice in the hands of individuals and small businesses.

Sections 1311(e)(3)(A)-(C) of the Affordable Care Act, as implemented at 45 CFR 155.1040(a)-(c) and 156.220, establish new standards for qualified health plan (QHP) issuers to submit specific information related to transparency in coverage. QHPs are required to post and make data related to transparency in coverage available to the public.

Community Health Choice is providing all required data elements below. Please click on the links to obtain additional information about each data element.

  • Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing.
  • Out-of-Network and Balance Billing
  • Evidence of Coverage (Deductible Plans)

If you believe you have paid too much for your premium and should receive a refund, please call Community’s Marketplace Member Services at 713-295-6704 or Toll-Free 1-855-315-5386. You may also email us at [email protected]

Medical Necessity Definition: Medical Necessity is the review of requested covered healthcare services or supplies needed to prevent, diagnose or treat a covered illness, injury, condition, disease or its symptoms in accordance with plan benefits.

Failure to obtain prior authorization may result in rejection or denial of benefits.

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