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Members

We Want to Give You Good Care!

Two Old Friends

Molina Medicare works with your providers to give you good health care. We make choices about your care based on what you need. We also look at your benefits. We do not reward providers to deny you care. We also do not reward staff or other people to deny you care or give you less care. We do not pay extra money to providers or our staff members to deny tests or treatments that you need to get better or stay healthy.

Please call Member Services, if you ever have a concern about your health care. You can also talk to our nurses about getting needed care. Our nurse staff is here to take your call 7 days a week (except holidays) during normal business hours. They can answer questions about how we make health care choices.

We also want to remind you that Molina Medicare has a Nurse Advice Line to help answer questions you may have about your health. There are nurses ready to help you 24 hours a day, 7 days a week.

 

Questions?

1. Where do I get care?
2. How do I change my provider?
3. How do I obtain interpreter services?
4. Why do I need a Referral or Authorization?
5. Who can I call with questions, concerns or complaints?
6. How does Molina Medicare look at new services?
7. How do I get behavioral health services?
8. When do I get my new member handbook and ID card?
9. What if I need a dentist?
10. What if I need vision care?
11. How can I get specialty care?
12. What do I do if I am out of my area and need to see a provider?
13. How do I make an appointment?
14. What do I do if my provider's office is closed?
15. What if I need emergency care?
16. What if I believe I qualified for "Extra Help"?

*Printed copies of information posted on our web site are available upon request.

 

 

1. Where do I get care?

You should get all health care from Molina Medicare providers. These are providers who have a contract with Molina Medicare. Your Provider Directory lists them all. It also lists other places you can go. You can get care at some approved offices like:

  • Health centers
  • Rural health clinics
  • Family planning providers
  • Community mental health centers

These should be Medicare providers. We update the Provider Directory quarterly (every three months) and mail it to you when you are first enrolled and upon request. It tells you where you can get health care. If you get routine care from a provider who does not have a contract with Molina Medicare, you may have to pay for that care. In an emergency you can see any provider. It does not need to be a Molina Medicare provider.

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2. How do I change my Primary Care Provider (PCP)?  

  • The Provider Directory has a list of Molina Medicare PCP's.
  • You can select a new PCP and call Member Services to notify us
Molina Medicare will send you a new ID card with the provider's name. The card also lists the effective date of the change.

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3. How do I obtain interpreter services?

You have a right to an interpreter. There is no cost to you. Tell the office staff if you would prefer to talk in your own language. If you need help, call Member Services.

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4. Why do I need a Referral or Authorization?


A "Referral" means you go somewhere else besides your regular PCP for service. Referrals may be written or by phone. Some services must be approved by your PCP or Molina Medicare. This is called an "Authorization". Your PCP will take care of any referrals you need.

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5.Who can I call with questions, concerns or complaints?

Our Member Services Department is available to assist you. Our staff is bilingual and can answer any question that you may have in regards to your health plan benefits.
Molina Healthcare also has a 24-hour Nurse Advice Line that you may call toll-free at (888) 275-8750 (English) or (866) 648-3537 (Spanish). A registered nurse can answer any question you may have regarding your health care.
Please remember that you may also speak to your PCP about your medical concerns. Your PCP and his/her staff are there to help.

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6. How does Molina Medicare look at new services?


We also look at new services. And we look at new uses for benefits you have now. We review new studies to see if services should be added to your benefit package. Molina Medicare reviews the type of services listed below at least once a year:

  • Medical services
  • Mental health services
  • Medicines
  • Equipment

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7. How do I get behavioral health services?


Molina Medicare wants you to have the help you need. We can help you get behavioral health services. We can find you help for drug and alcohol abuse. Call Molina Medicare Member Services for information.
You can access behavioral health services such as:

  • Providers
  • Nurses
  • Psychologists
  • Social workers

These providers are trained to help you with psychiatric and emotional problems.


Behavioral health services include:
  • Inpatient
  • Outpatient hospital services
  • Psychiatric provider services
  • Individual, family, and group therapy
  • Treatment provided by a psychiatrist or behavioral health provider
  • Social rehabilitation
  • Day treatment for adults and children
  • Individual and family assessments

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8. When do I get my new member evidence of coverage and ID card?

You should receive your Member Evidence of Coverage and Molina Medicare ID Card the first or second week after your enrollment is effective with Molina Medicare.

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9. What if I need a dentist?

As a Molina Medicare member, you have access to dental services. If you need dental services, you may get care from any dentist listed in our network. You may also contact Member Services for help finding a dentist.

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10. What if I need vision care?

As a member of Molina Medicare, you have access to vision care. To find the vision care provider nearest you, contact Member Services for help. You do not need a referral from your PCP for routine vision care.

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11. How can I get specialty care?

  • Within 24 hours for urgent care, but care that does not threaten your life. This is care that can be done in a provider's office

 

Please contact Member Services if you cannot get an appointment when you need one.

Don't forget to bring your Medicare card with you to all of your provider's visits. Also, be sure to bring your Molina Medicare member ID card with you as well. Please be on time so that you can be seen as scheduled.

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12. What do I do if I am out of my area and need to see a provider?

When you travel away from your hometown, Molina Medicare pays for emergency care for you. You may go to a local emergency room (ER) or an urgent care clinic. Tell them you are a Molina Medicare member. Show them your Molina Medicare ID card. Routine care, such as normal provider visits or pre-planned surgery, is not covered outside of your service area.

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13. How do I make an appointment?

You should be able to get an appointment with your Primary Care Provider (PCP) as follows:

  • Within 14 days for routine, non-urgent care
  • Within 60 days for school physicals
  • Within 24 hours for urgent care, but care that does not threaten your life. This is care that can be done in a provider's office
Please contact Member Services if you cannot get an appointment when you need one.

Don't forget to bring your Medicare card with you to all of your provider's visits. Also, be sure to bring your Molina Medicare member ID card with you as well. Please be on time so that you can be seen as scheduled.

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14. What do I do if my provider's office is closed?


There may be times when you may need care and your Primary Care Provider (PCP) is closed. If it is after hours and your PCP's office is closed you can call your PCP or Molina Medicare's Nurse Advice Line. Nurses are available to help you at any time of the day. Call (888) 275-8750, 24 hours a day, 7 days a week.

Molina Medicare's Nurse Advice Line has highly trained nurses. They can help you decide if you or your child should see a provider right away. The nurses can also help you make an appointment if you need to see a provider quickly.

Sometimes, you have questions but you do not think you need to see your PCP. You can call the Nurse Advice Line and talk to a nurse. They will help you.

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15. What if I need emergency care?


Emergency care is for sudden or severe problems that need care right away. It can also be care that is needed if your life or health is in danger. Emergency care is a covered benefit. If you need emergency care, call 911 or go to the nearest hospital. You do not need prior approval. If you have an urgent matter that does not threaten your life, you can also call Molina Medicare's Nurse Advice Line. Highly trained nurses are available to help you at any time of the day. Call (888) 275-8750, 24 hours a day, 7 days a week.

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16. What if I believe I qualified for "Extra Help"?

If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper co-payment level, or, if you already have the evidence, to provide this evidence to us.

The Best available evidence (BAE) is used to determine a member’s Low Income Subsidy. Our Member Services department and Pharmacy department identify cases where the BAE policy applies. Members may send BAE documentation to establish eligibility to the Member Services address listed in Chapter 2 or they may call Member Services to request assistance.

Acceptable forms of evidence are:

  • SSA Award Letter
  • Notice of Award
  • Supplemental security Income

 

When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you.

Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state.

Please contact Member Services if you have questions.

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