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 for the following:
• Emergency services
• Post stabilization services, unless you waive balance billing protections
• Services from a non-participating provider at a participating facility, unless you waive balance billing protections
• Air ambulance services
• Services from a non-participating provider that are subject to prior authorization
• Exceptions described in the member Agreement's "Access to Care" section in the subsections titled "Non-Participating Provider at a Participating Provider Facility," "No Participating Provider to Provide a Covered Service," "Continuity of Care," and "Transition of Care”
To locate a participating provider, please refer to the provider directory at MolinaMarketplace.com or call Member Services. Because non-participating providers are not in Molina's contracted provider network, unless balance billing protections apply, they may balance bill Members for the difference between Molina's allowed amount and the rate that they charge. Members may avoid balance billing by receiving all covered services from participating providers.
Once you have obtained covered services from a participating provider, the provider is responsible for submission of claims to Molina for determination of payment under your plan. You are not responsible for submitting claims to Molina for payment of benefits under your plan.
However, if a participating provider fails to submit a claim, you may wish to send receipts for covered services to Molina. With the exception of any required cost sharing amounts (such as a deductible, copayment or coinsurance), if you have paid for a covered service or prescription that was approved or does not require approval, Molina will pay you back. You must submit your claim for reimbursement within 20 days from the date you made the payment or as soon as reasonably possible.
Please refer to your evidence of coverage, policy or certificate. You will need to mail a copy of the bill from the doctor, hospital or pharmacy and a copy of your receipt and the Member’s Name, Subscriber ID, and Date of Birth. If the bill is for a prescription, you will need to include a copy of the prescription label. Mail this information to Molina’s customer support center at the following address:
Molina Healthcare of South Carolina, Inc.
Member Services
PO Box 40309
North Charleston, SC 29423
1 (855) 885-3176
A grace period is a period of time after a member’s premium payment is due and has not been paid in full. If a subscriber hasn’t made full payment, they may do so during the grace period and avoid losing their coverage. The length of time for the grace period is determined by whether or not the subscriber receives an advance payment of the premium tax credit (APTC).
- Grace Period for Subscribers with No APTC: Molina will provide a Grace Period of 31 consecutive days for a Subscriber and their Dependents, who when failing to timely pay Premiums, are not receiving an APTC. The Grace Period will begin the first day of the first month for which full Premium is not received by Molina. During the Grace Period, Molina will pay all appropriate claims for services rendered to the Subscriber and their Dependents. Molina will terminate this Agreement as of 11:59 p.m. Eastern on the last day of the Grace Period if Molina does not receive all past due Premiums from the Subscriber. You will still be responsible for any unpaid premiums you owe Molina for the grace period.
- Grace Period for Subscribers with APTCs: Molina will provide a Grace Period of 3 consecutive months for a Subscriber and their Dependents, who when failing to timely pay Premiums, is receiving an APTC. The Grace Period will begin the first day of the first month for which full Premium is not received by Molina. During the Grace Period, Molina will pay all appropriate claims for services rendered to the Subscriber and their Dependents during the first month of the Grace Period and may pend claims for services in the second and third months of the Grace Period. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If all premiums due and owing are not received by the end of the three-month grace period, Molina will terminate this Agreement as of 11:59 p.m. Eastern on the last day of the first month of the Grace Period. You will still be responsible for any unpaid premiums you owe Molina for the grace period.
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.
If you believe you have paid too much for your premium and should receive a refund, please contact Member Services using the telephone number on the back of your ID card.
Medical Necessity or Medically Necessary means health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
A prior authorization is an approval from Molina for a requested health care service, treatment plan, prescription drug or durable medical equipment. A prior authorization confirms that the requested service or item is medically necessary and is covered under your plan. Molina’s Medical Director and your doctor work together to determine the medical necessity of covered services before the care or service is given. This is sometimes also called prior approval.
You should consult your agreement 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.
For routine prior authorization requests, Molina will provide a decision within five (5) business days from receipt of all information reasonably necessary and requested by Molina to make the determination.
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. These are considered urgent requests.
Molina has a list of drugs, devices, and supplies that are covered under the plan's pharmacy benefit. The list is known as the formulary. The formulary shows prescription and over-the-counter products plan members can get from a pharmacy using Molina coverage. It also shows coverage requirements, limitations, or restrictions on the listed products. The formulary is available at
www.MolinaMarketplace.com. A hardcopy is also available upon request.
If your prescription drug is not listed on the formulary, your provider may request a formulary exception by sending a form and supporting facts to let Molina know how the drug is medically necessary for your condition. The process is similar to requesting prior authorization for a formulary drug.
The pharmacy "Universal Prior Authorizations Medications Form" and directions for completing the request can be found
here.
Molina Marketplace
Member Services: (855) 885-3176
Provider Services: (855) 237-6178
Fax: (855) 571-3011
If the request is approved, we will notify your provider. If it is not approved, we will notify you and your provider, including the reasons why. Drugs that are not on the formulary may cost you more than similar drugs that are on the formulary if covered on exception.
There are two types of formulary exception requests:
Expedited exception request – this is for urgent circumstances that may seriously jeopardize your life, health, or ability to regain maximum function; or for requesting nonformulary prescription drugs you have already been taking for a while. Drug samples given to you by a provider or a drug maker will not count as drugs you have been taking for a while. To have your request expedited, indicate on the form that the request is urgent.
Standard exception request – this is for non-urgent circumstances.
Notification - following your request, we will send you and/or your provider notification of our decision no later than:
- 24 hours following receipt of an expedited exception request
- 72 hours following receipt of a standard exception request
If you think your request was denied incorrectly, you and your provider may seek additional review by Molina or an Independent Review Organization (IRO). Details are outlined in the notification you will receive with the reasons why the exception request was denied.
Information about cost sharing amounts can be found on our benefits at a glance brochure or by entering your prescription and pharmacy information into the check drug cost tool. To use the check drug cost tool, click on the “Drug Look-Up” link for your plan on our view plans webpage.
Please note: Cost sharing for any prescription drugs obtained by you using a prescription drug manufacturer discount card or coupon, will not apply toward any deductible or annual out-of-pocket maximum under your plan.
Each time we process a claim submitted by you or your health care provider, we explain how we processed it in the form of an explanation of benefits (EOB). The EOB is not a bill. It simply explains how your benefits were applied to that particular claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.
Coordination of benefits, or COB, is when you are covered under one or more other group or individual plans, such as one sponsored by your spouse's employer. An important part of coordinating benefits is determining the order in which the plans provide benefits. One plan is responsible for providing benefits first. This is called the primary plan. The primary plan provides its full benefits as if there were no other plans involved. The other plans then become secondary. Further information about coordination of benefits can be found in your agreement.
Visit
www.MolinaMarketplace.com to see if you qualify for financial assistance and enroll into a Molina plan. You can also speak to one of our Certified Enrollers who can help you apply over the phone by calling (833) 946-1037, or you can
find a certified enrollment partner in your area who can assist you in person.
Open enrollment for 2024 is November 1, 2023 through January 15, 2024.
Complete your enrollment application by December 15, 2023, for a January 1, 2024 effective date.
Many of us do not think about health care until we need it. However, health care is important at all times – for preventative care and for unexpected emergencies.
Conditions that may 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:
- Getting Married, divorced or legally separated
- Have a child, adopt a child, or place a child for adoption
- Death of someone on your plan
- Change your place of residence
- Have a change in income or household size
- You lose your health coverage, including no longer being eligible for Medicaid, losing your coverage through your job, or exhausting your COBRA coverage
- Have a change in disability status
- You return from active-duty military service
- You become a citizen, national or lawfully present individual
- If you are a member of a federally recognized American Indian or Alaska Native tribe, you can enroll anytime and change plans no more than once per month.
- Leaving incarceration
Other qualifying life events may apply. For more information, visit healthcare.gov.
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.
Without health insurance, you may suffer catastrophic financial losses due to illness or injury.
Health plans in the Marketplace cannot deny health insurance coverage because of a medical condition you had before signing up for coverage. Coverage for any pre-existing medical condition you may have begins the effective date of your coverage.
- If you apply between November 1, 2023, and December 15, 2023, the effective date of your coverage is January 1, 2024.
- If you apply between December 16, 2023, and January 15, 2024, the effective date of your coverage is February 1, 2024.
- The effective date of coverage will be determined by the Marketplace. The Marketplace and Molina will provide special monthly enrollment periods for eligible American Indians or Alaska Natives.
Within 10 days after you pay your first premium. For coverage starting on the first of the month we will send out ID cards approximately the 26th of the month.
To make a payment for your monthly premium, go to MyMolina.com and click on the $ icon. We provide several payment options for your convenience. We accept Visa, MasterCard and Discover Card or electronic check. You can also sign up for automatic payments through AutoPay. It is convenient and worry free!
For additional ways visit our Make a Payment page.
-
If you are a new member, you will receive a paper invoice within 7-10 business days after enrollment.
-
If you are a renewing member, you will receive an invoice by the 15th of every month.
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.
If your payment is not reflected on your recent invoice, it may have been received after the invoice was generated. Check the date on your invoice compared to the date your payment cleared your bank account. If you don’t have your paper invoice, you can find it on
MyMolina.com.
Feel free to
contact us if you need additional assistance.
Please visit your Auto Pay account in your
My Molina online member account located here.
If you are having trouble,
contact us and we can help.
Yes, it is easy to do so by setting up your
My Molina online member account and following the prompts to make a payment, which will lead you to the Auto Pay options.
Electronic Funds Transfer (EFT), checking account, or credit card, by visiting your
My Molina online member account.
Payments are due on the last calendar day of the month.
3-5 business days depending on how long it takes your bank to process the transaction.
Auto payments will be processed on the last day of the month or the next business day if the last day falls on a weekend or holiday, for the total balance due of your health insurance premiums. This remains in effect for as long as you are covered with Molina, or until you cancel AutoPay, whichever comes first.
We accept only one auto-payment per month, which will be deducted from your account in full.
Please register and/or sign into your
My Molina online member account to find out your balance, or call the customer support number
located
here.
Molina needs to have a power of attorney or PHI form in your file indicating the caller is authorized, if the caller is not authorized the member can provide a verbal consent. The verbal consent will grant the caller permission to speak on their behalf, but it is only good for 14 business days. At the member’s request, Molina can send a PHI form to the address on file to avoid future verbal consents.
Visit
mymolina.com and click on “Forgot User ID or Password?” and follow all the steps to complete the password reset.
Updates to your address or contact information may impact your coverage. You will need to contact the
Exchange to update your contact information.
You can register on the
My Molina online member portal once your initial payment is processed and you become effective with the plan.
Once we receive your initial payment, you will receive your new ID card in the mail within 5-7 business days.
If you need a replacement or additional ID card, you can view and print one within your secure
My Molina online member account.
Go to
MyMolina.com and register your personal online member account today!
If you are having trouble,
contact us and we can help
Your
My Molina online member account is a powerful tool that puts you in control of your health coverage. It’s easy to set up and lets you manage your account wherever you are on a computer or your smart phone.
Use your
My Molina online member account anytime to conveniently do things like:
- Access your digital ID card and download view it to your smart phone, or print it or request a new ID card to be sent to your current address on file with Molina
- Choose or change your Primary Care Physician (PCP)
- View Billing Information
- Make a Payment
- Sign up for automatic monthly payment through AutoPay
- Check to see if we cover your prescription drugs
- Quick links to benefit coverage and much more!
Go to
MyMolina.com and register your personal online member account today!
Setting up your
My Molina online member account is easier than ever- it only takes a few minutes.
Go to
MyMolina.com and complete a few simple steps to register. Be sure to have your Member ID number, Date of Birth, and State where you are enrolled.
MyMolina.com can be accessed by your desktop or mobile device.
You can download “My Molina Mobile” from your app store using your smart phone.
My Molina Mobile is a self-service mobile application for Molina members. My Molina Mobile has many features and will allow you to have the same access as your
My Molina online member account.
Yes. For more information or to create an account, visit the
Virtual Care page.
To view your specific benefit coverage, visit your
My Molina online member account.
As of 12/31/2023 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.
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.
Please go to Healthcare.gov and update your information.
Yes, you and your dependents will be automatically enrolled in Molina, if they were
covered by your previous insurer.
If you are eligible for tax credits and your family size and/or income has not changed,
you will continue to receive tax credits.
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.
Yes, but you need to continue to pay your current/previous insurer until the end of the year.
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.
After you make your initial payment, you will receive your ID card within 10 days.
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.
For your convenience, we have a Provider Online Directory where you can search for available choices in your area. Go to Provider Online Directory
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
To view all of our covered formularies, go to Molina Healthcare Drug Formulary
You can contact member services to answer any questions you may have
Find helpful resources, plan materials, payment information and more.
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