Will I be responsible for any out of pocket costs billed by a Non-Participating (Out
of Network) Provider?
PLEASE NOTE: Urgent Care is not covered if a member is treated by a non-participating
In general, You must receive Covered Services from Participating Providers;
otherwise, the services are not covered, You will be 100% responsible for payment
to the Non-Participating Provider, and the payments will not apply to Your Deductible
or Annual Out-of-Pocket Maximum. However, You may receive services from a Non-Participating
1) for Emergency Services in accordance with the section of the Agreement titled
“Emergency Services and Urgent Care Services”, and
2) for exceptions described in
the section of this Agreement titled “What if There Is No Participating Provider
to Provide a Covered Service?,”
How are claims for covered medical services submitted for payment under my plan?
In most cases, Participating Providers will ask You to make a payment toward Your
Cost Sharing at the time You check in. Keep in mind that this payment may cover
only a portion of the total Cost Sharing for the Covered Services You receive. The
Participating Provider will bill You for any additional Cost Sharing amounts that
The Participating Provider is not allowed to bill You for Covered Services You receive,
other than for Cost Sharing amounts that are due under this Certificate. However,
You are responsible for paying charges for any health care services or treatments
1. not Covered Services under this Certificate, or
2. provided by a Non-Participating
What is my grace period?
- If You do not receive advance payment of the premium tax credit: A grace period
of 31 days will be granted for the payment of each premium falling due after the
first premium, during which grace period the policy shall continue in force. Molina
will process payment for Covered Services received during the 31 day grace period.
You will be responsible for any unpaid Premiums You owe Molina Healthcare for the
- If You receive advance payment of the premium tax credit: A grace period of 3 months
will be granted for the payment of each premium falling due after the first premium,
during which grace period the policy shall continue in force.
- Molina will process payment for Covered Services received during the first month
of the grace period. You will be responsible for any unpaid Premiums You owe Molina
Healthcare for the first month of the grace period.
- Molina will hold payment for Covered Services received after the first month of
the grace period until We receive the delinquent Premiums. If Premiums are not received
by the end of the 3-month grace period, You will be responsible for payment of the
Covered Services received during the second and third months.
What is a retroactive denial and when am I responsible?
A retroactive denial is the reversal of a previously paid claim. This retroactive denial may occur even after you obtain services from the provider (doctor). If we retroactively deny the claim, you may become responsible for payment. The ways to prevent retroactive denials are paying your premiums on time, and making sure you doctor is a Participating (In-Network) Provider.
How do I recover an overpayment to Molina?
If You believe that We have not paid a claim properly, You should first attempt
to resolve the problem by contacting us. Follow the steps described in the "Complaints"
section, below. If You are still not satisfied, You may call the Michigan Department
of Insurance and Financial Services DIFS for instructions on filing a consumer complaint.
Call 1 (877) 999-6442 or visit the Department’s website at http://www.michigan.gov/difs/0,5269,7-303-12902_12907---,00.html
What is Medical Necessity?
“Medically Necessary” or “Medical Necessity” means health care services that a physician,
exercising prudent clinical judgment, would provide to a patient. This is for the
purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease
or its symptoms. Those services must also be deemed by Molina to be:
- In accordance with generally accepted standards of medical practice;
- Clinically appropriate and clinically significant, in terms of type, amount, frequency,
level, extent, site and duration.
- Effective for the patient’s illness, injury or disease; and
- Not primarily for the convenience of the patient, physician, or other health care
provider. The services must not be more costly than an alternative service or sequence
of services at least as likely to produce equivalent therapeutic or diagnostic results
as to the diagnosis or treatment of that patient’s illness, injury, or disease.
For these purposes, “generally accepted standards of medical practice” means standards
based on credible scientific evidence published in peer-reviewed medical literature.
This literature is generally recognized by the relevant medical community, physician
specialty society recommendations, the views of physicians practicing in relevant
clinical areas and any other relevant factors.
What is Prior Authorization, and how does it impact services under my plan?
Your plan requires that you obtain a medical necessity review of certain services,
prior to obtaining those services to be covered under your plan. Prior authorization
is a process for Molina and your doctor, to review the medical necessity of your
care before the care or service is given. This is to ensure that the proposed services
are appropriate for your specific condition and that appropriate utilization review
You should consult your evidence of coverage, policy or certificate, to determine
what services require prior authorization under your plan. If you do not obtain
prior authorization for the specified services, claims for benefit payment may be
denied, impacting your out of pocket costs.
Routine prior authorization requests will be processed within 5 business days of
receiving complete information from your doctor, and Molina will respond to prior
authorization requests within 14 calendar days.
Medical conditions that may cause a serious threat to your health are processed
within 72 hours from receipt of all information, or shorter as required by law.
How can I determine if my prescription drug is covered?
What do I do if my prescription drug is not listed in my Plan’s formulary?
Molina Healthcare has a list of drugs that We will cover. The list is known as the
Drug Formulary. The drugs on the list are chosen by a group of doctors and pharmacists
from Molina Healthcare and the medical community.
The group meets every 3 months to talk about the drugs that are in the Drug Formulary.
They review new drugs and changes in health care, in order to find the most effective
drugs for different conditions. Drugs are added to or removed from the Drug Formulary
based on changes in medical practice and medical technology. They may also be added
to the Drug Formulary when new drugs come on the market.
You can look at Our
Drug Formulary on Our Molina Healthcare website at MolinaMarketplace.com. You may
call Molina Healthcare and ask about a drug. Call toll free 1 (888) 560-4087, Monday
through Friday, 8:00 a.m. through 5:00 p.m. ET. If You are deaf or hard of hearing,
call toll-free 1 (888) 665-4629 or dial 711 for the Telecommunications Relay Service.
You can also ask Us to mail You a copy of the Drug Formulary. Remember that
just because a drug is on the Drug Formulary does not guarantee that Your doctor
will prescribe it for Your particular medical condition.
What is an Explanation of Benefits (EOB)?
An explanation of benefits (EOB) is a statement Molina sends to you to explain what medical treatments and / or services Molina paid for on your behalf, the amount of the payment, and your financial responsibility pursuant to the terms of your policy. Molina will send you an EOB after you receive services from your doctor or a hospital.
In some instances there may be one or more reasons why payment or partial payment cannot be made. If your claim has been denied and you believe that additional information will affect the processing of the claim, or you have a question about a covered service, a provider, your benefits or how to use your plan, you can contact member services to answer any questions you may have.
Here are some of the definitions of the terms used in the EOB:
- Procedure code - code number of the service that was performed.
- billed amount - the amount of billed charges received from your provider for services rendered
- Allowed amount - the amount the health plan pays for services rendered
- Copay amount - the amount of your copay for certain benefits (i.e. office visit, ER, etc.). This is a fixed dollar amount.
- Co-insurance amount – the amount owed by you after your deductible is applied. This is based on a percentage dictated by your benefit coverage.
- Deductible amount - the amount applied toward your annual deductible, based on benefit coverage and claim.
- Plan payment - the amount the health plan paid to the provider.
- Remark code – additional messages that may explain how your claim was processed under "explanations of claims handling"
- Total patient responsibility for this claim - the amount you owe the provider.
- Description of remark code - explanation of the claim payment or denial.
- Family out of pocket & deductible totals - a summation of your family's total yearly deductible amount and out of pocket amount based on your benefits, the year to date total that has been applied, and the remaining balances.
What is Coordination of Benefits (COB)?
This Coordination of Benefits (“COB”) provision applies when a person has health
care coverage under more than one Plan. For purposes of this COB provision, Plan
is defined below.
The order of benefit determination rules govern the order in which each Plan will
pay a claim for benefits. The Plan that pays first is called the “Primary Plan”.
The Primary Plan must pay benefits in accordance with its policy terms without regard
to the possibility that another Plan may cover some expenses. The Plan that pays
after the Primary Plan is the “Secondary Plan”. The Secondary Plan may reduce the
benefits it pays so that payments from all Plans do not exceed 100% of the total