Molinalogo

1. for emergency services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,”
2. for out-of-area urgent care services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,” and
3. for exceptions described in the section of the Agreement titled “What if There Is No Participating Provider to Provide a covered service?”

• not covered services under the Agreement, or
• provided by a Non-Participating Provider, except that Molina will cover 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,”
2. for out-of-area urgent care services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,” and
3. for exceptions described in the section of this Agreement titled “What if There Is No Participating Provider to Provide a covered service?”

• 31-day grace period to pay the full premium payment due if you do not receive advance payment of the premium tax credit. Molina will process payment for covered services received during the 31-day grace period and your coverage will remain in effect during this time.  You will be responsible for any unpaid premiums you owe Molina for the grace period ; or,
• Three month grace period to pay the full premium payment due if you receive advance payment of the premium tax credit. Molina will process payment for covered services received after the first month of the grace period so long as your premiums are paid in full before the end of the grace period . If We do not receive premiums 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.

• In accordance with generally accepted standards of medical practice;
• Clinically appropriate and clinically significant, in terms of type, frequency, 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.

• 24 hours following receipt of request for expedited exception request
• 72 hours following receipt of request for standard exception request

• 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.

• 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
• You lose your health coverage, including no longer being eligible for Medicaid or losing your coverage through your job
• Get Health coverage through a job or a program like Medicare or Medicaid
• Have a change in disability status
• Become pregnant
• 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.
• Experience other changes that may affect your income and household size

Other qualifying life events may apply. For more information, visit HealthCare.gov

• If You apply on or before December 15, 2019, the Effective Date of Your coverage is January 1, 2020.
• Applications made after December 15, 2019 are subject to Special Enrollment Period requirements and verification.
• 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.

As of 12/31/2019 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.

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

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