About Molina Complete Care and Managed Care
Molina Complete Care
Molina Complete Care (MCC) is a health plan, or managed care organization. We give access to both behavioral and physical health services.
We help members who are eligible for Medicaid and KidsCare benefits get the behavioral and physical health services they need.
If you’re eligible for Medicaid or KidsCare, you’ll have a health plan. We’ll work with your doctors and providers to pay for your medical services, help you get rides to your appointments, help get you the prescriptions and medical equipment you need and more.
Your Primary Care Provider
Your primary care provider (PCP) is your doctor who will give you the health care services you need. Your PCP is your personal doctor who will manage all of your health care. They are the “gatekeeper” for your health. This means that they will arrange for most of your health care needs. Your PCP is your doctor who will give you the health care services you need.
You should see your PCP for your annual visit, your well visits and times when you’re feeling sick. Going to your PCP for your health care help you build a relationship so they know you and your health history. They’ll understand your health care needs. If you need specialty care, they can refer you to a specialist. Your PCP may treat behavioral health conditions too. If you have a behavioral health condition, your PCP may decide to refer you to a behavioral health specialist to manage your care. It’s important to let your PCP know if there have been any changes to your health. This way they can give you the care that you need. Your PCP should know about any other providers you’re seeing and if they’ve given you any medicine(s).
Your PCP plays an important role in making sure all of your health care is coordinated between all of your providers. Your PCP can help with health issues like:
- Substance use disorders
- Attention Deficit Hyperactivity Disorder (ADHD)
And so much more!
If you have any questions, want to change your PCP or get help with making an appointment, you can call Member Services at (800) 424-5891 (TTY/TDD: 711).
Seeing a Specialist
Your PCP is who you should see for most of your health care needs. Sometimes you may need specialty care. If you need specialty care, you’ll need to talk to your PCP and get a referral to a specialist.
There are times when you don’t need a referral for a specialist. This is called a “self-referral”.
- Women can see an in-network OB/GYN for preventive and routine services
- All members can self-refer for services with an in-network behavioral health provider
- Members under 21 years of age can self-refer for dental and vision screenings with in-network dentists and vision providers
- Members with special health needs may directly access health care services from a specialist as needed for their condition and needs
To use the “self-referral” process, call the providers directly to make an appointment. You don’t have to go through your PCP first. If you need help finding a provider, please call Member Services or search our Provider Online Directory [insert POD link]. Services that’re provided out-of-network providers will need a prior authorization first.
MCC will also get you care outside of our network when the type of provider needed and available in our network doesn’t provide the service you need. This includes counseling or referring services because of moral or religious objections. For information on how to access counseling or referral services, please call Member Services at (800) 424-5891 (TTY/TDD: 711).
Getting Care from Out-of-Network Providers
Molina Complete Care (MCC) is a managed care plan. You should use the providers in our contracted network. You can call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday-Friday 8 am-6 pm local time/MST to check if a provider is in our network.
Normally, we don’t pay for out-of-network care, but there are exceptions. Those exceptions include:
- Emergency care
- Family planning services
- Coming from another health plan
- A lack of providers within certain time and distance standards
However, if we don’t have a specialist in the MCC network to give you the care you need, we will get you the care you need from a specialist outside of our network. You can ask your PCP to submit an authorization to see an out-of-network provider.
An out-of-network provider can also ask for a prior authorization to treat you. If the request is approved, you can see the out-of-network provider.
If you present to a non-contracted provider, please call Member Services so we can help you find an in-network provider.
If you need care during the workday, call your PCP. If you’re not able to see your PCP or if it’s after hours, you can go to one of the urgent care centers we work with.
To find a list of urgent care centers, visit [POD link] or call Member Services at (800) 424-5891 (TTY/TDD: 711).
If you’re having an illness or injury that could cause serious injury or death if it’s not treated right away, please call 911 or go to the closest emergency department (ED) right away. You don’t have to call MCC first. Prior authorization isn’t needed for emergency services. You can go to any hospital for emergency care, even if you’re in another city or state.
Go to the ED when you have a serious problem that needs care right away. Emergencies include, but aren’t limited to:
- Heart attack or stroke symptoms
- Severe bleeding
- Severe trouble breathing
- Severe pain
Let the hospital know you’re an MCC member and show them your member ID card.
Out of Area Care
If you’re away from MCC’s service areas and need emergency care, go to the nearest emergency room for care. Please contact MCC within 24 hours or as soon as you can. Call toll-free (800) 424-5891. If you are deaf or hard of hearing, call our dedicated TTY/TDD line toll-free 711. When you are away from MCC’s service area, only emergency care is covered. *Out of area urgent care services require prior authorization. No services are covered outside the United States.
Urgently needed care is care you need for a non-life-threatening sudden illness, injury or condition that isn’t an emergency but needs attention right away. Urgent care clinics can provide care for problems that include, but aren’t limited to:
- Broken bones
- Sore throats
- Skin rashes
- Minor cuts
- Routine health care, including, but not limited to:
- Sports physicals
Urgent care clinics are open after hours and on the weekends. You can walk in or call to make an appointment.
You or your doctor has the right to ask for a second opinion. You or your doctor can call Member Services at (800) 424-5891 (TTY/TDD: 711) to request the second opinion.
If the request is urgent and serious:
- MCC will respond within one (1) day
- The second opinion will be given within 72 hours
Reasons why second opinions are needed:
- You are not sure you need the treatment the doctor suggests
- You are not sure of the doctor’s diagnosis
- You have a complex problem
- Your doctor is not sure of a correct diagnosis
- You have complex symptoms
- You have followed the doctor’s care plan but have not improved
- You have talked with your doctor about your concerns but still are not satisfied
If a second opinion is approved, you will not have to pay for the services. The doctor that you see for a second opinion will send a written report to you and your PCP.
MCC may decide a second opinion is not needed. If so, we will send you a denial with the appeal rights.
Culturally competent materials and services
If you need help understanding information, MCC provides no-cost help and services, including auxiliary aids, to people with disabilities. We want you to be able to communicate with us easily. We offer:
- Qualified sign language interpreters
- Written information in many formats. These may include:
- Large print
- Accessible electronic formats
- Other formats
Call us at (800) 424-5891 (TTY/TDD: 711) if you need any of these services.
If you don’t speak English, we provide language services at no cost to people whose first language isn’t English. We offer:
- Qualified interpreters
- Information that’s written in other languages
We indicate which providers speak other languages in our Provider Online Directory. To find a provider who speaks another language, please visit [Health Plan URL] and choose [insert whatever the option is for finding a provider]. The MCC provider directories will let you know if a provider’s office has interpreter services available. If you have any other cultural needs or if you need help finding a provider that speaks a language other than English, please call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday-Friday 8 am-6 pm local time/MST.