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Frequently Asked Questions

You can find answers to your questions below! A​lso, check out our glossary​ to look up any words that may be confusing. Don’t see your question? Just give us a call!

  •  Transparency in Coverage
    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 provider!
    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 Provider:
    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 are due.

    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 that are:

    1. not Covered Services under this Certificate, or
    2. provided by a Non-Participating Provider.
    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 grace period.
    • 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 can occur.

    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 Allowable Expense.
  •  Enrollment
    When is Open Enrollment? Open enrollment for 2017 has ended. Individuals may qualify for enrollment outside of Open Enrollment through a Special Enrollment Period.

    Open enrollment for 2018 is November 1, 2017 through December 15, 2017.
    What is a Special Enrollment Period Conditions that qualify for a Special Enrollment Period include the following life events. Contact the Health Insurance Exchange in your state if any of the following conditions impact you, or you need additional clarification:
    • Not aware of penalty for not having health insurance (specific dates apply)
    • Getting Married or divorced
    • Have a child, adopt a child, or place a child for adoption
    • Have a change in income
    • Get Health coverage thorough a job or a program like Medicare or Medicaid
    • Change your place of residence
    • Have a change in disability status
    • Gain or lose a dependent
    • Become pregnant
    • Experience other changes that may affect your income and household size
    What if my income changes or my family size changes? Do I need to do anything?
    • If your income or household size has changes, you will need to report that to the Marketplace in your state, so that you get the right Premium Tax Credit you may be able to receive. Please go to Healthcare.gov and update your information.
  •  Billing
    How will my premiums be impacted? If you are eligible for premium assistance (Premium Tax Credits), you could save even more money. Contact the Marketplace in your state, so that you get the right Premium Tax Credit you may be able to receive. Please go to Healthcare.gov and update your information.
    I have an issue with my auto-payment. What should I do? Please visit your Auto Pay account in your MyMolina portal located here.
    Can I set up an auto-payment? Yes, it is easy to do so by setting up your MyMolina account and following the prompts to make a payment, which will lead you to the Auto Pay options.
    What types of payment are accepted for auto-payments? Electronic Funds Transfer (EFT), checking account, or credit card, by visiting your MyMolina account.
    When will my auto-payment be taken from my account? On the 23rd of every month.
    Can I set up an auto-payment for a portion of my premium more often than once a month? We accept only one auto-payment per month, which will be deducted from your account in full.
    I have not received an invoice. How do I find out what I owe Molina? Please register and/or sign into your My Molina account to find out your balance, or call the customer support number located here.
  •  Provider and Pharmacy Network
    How do I know which doctors I can go to? You can choose a Primary Care Provider. To determine who might be best for you, go to the Provider Online Directory.
    How do I know what pharmacies to go to? Your pharmacy network is through CVS. You can see which pharmacies are available to you. Go to Pharmacy locator.
  •  Member Services
    I enrolled in a Molina plan. When can I register on the "My Molina" Member portal to see my benefits and services? You can register on the My Molina Member Portal within a week after enrolling and paying your first month’s premium.
  •  Were you automatically enrolled to Molina from another insurance carrier?

    Who automatically enrolled me with Molina, I did not sign up with Molina?

    As of 12/31/2017 your current health plan will no longer offer your plan in your area. Based on the description of your current Health Plan, the exchange assigned a similar plan, with the lowest cost, to meet your healthcare needs.

    Can I choose a different carrier?

    Yes. You may select a different health plan until December 15, for a January 1 start date. Please go to Healthcare.gov to review your plan options.

    What if my income has changed?

    Please go to Healthcare.gov and update your information.

    Will my whole family move from my previous health plan to Molina?

    Yes, you and your dependents will be automatically enrolled in Molina, if they were covered by your previous insurer.

    I am moving from one state to another during open enrollment

    Whenever you make a permanent move, you must update your address on Healthcare.gov, Covered California or HealthPlanFinder (WA).

    Will I still receive my subsidies/APTC/Tax Credits?

    If you are eligible for tax credits and your family size and/or income has not changed, you will continue to receive tax credits.

    Where do I find more information on my benefits?

    Log in to www.MyMolina.com to view your personal benefit information. If you don’t already have an account, you can register for one using your Member ID.

    What if I need treatment or services before January 1st? Will I get my treatment?

    Yes, but you need to continue to pay your current/ previous insurer until the end of the year.

    What are my new benefits?

    Log in to www.MyMolina.com to view your personal benefit information. If you don’t already have an account, you can register for one using your Member ID.

    When will I get my new ID card?

    After you make your initial payment, you will receive your ID card within 10 days.

    Are my premiums going to go up?

    While all the efforts are being made to keep your premiums low, premiums may increase depending on your family size and/or income. You will be notified by Molina through your monthly invoice on the exact monthly premium amounts.

    How do I find a doctor in my area?

    For your convenience, we have a Provider Online Directory where you can search for available choices in your area. Go to Provider Online Directory

    Can I keep my current doctor?

    Yes, If your doctor is in Molina’s network. To find out if your doctor is in Molina’s network, go to Provider Online Directory

    I am currently taking prescribed medication. How do I check to see if Molina will cover my medicine?

    To view all of our covered formularies, go to Molina Healthcare Drug Formulary

    Who can I call if I have questions?

    You can contact member services to answer any questions you may have

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