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Frequently Asked Questions

You can find answers to your questions below! Also, 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? 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,”
    2. for exceptions described in the section of the Agreement titled “What if There Is No Participating Provider to Provide a Covered Service?,” and
    3. for exceptions described in the section of the Agreement titled “Second Opinions From Non-Participating Providers."
    How are claims for covered medical services submitted for payment under my plan? 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 12 months from the date you made the payment.

    Please refer to your evidence of coverage, policy or certificate. You will need to mail or fax Molina, a copy of the bill from the doctor, hospital or pharmacy and a copy of your receipt. 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.

    Molina Healthcare of Florida, Inc.
    Customer Support
    8300 NW 33 St., Suite 400,
    Doral, FL 33122
    1 (888) 560-5716
    What is my grace period? If You have received a Late Notice that Your coverage is being terminated or not renewed due to failure to pay Your Premium, Molina will give a:

    • 10-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 10-day grace period. 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 three-month grace period, You will be responsible for payment of the Covered Services received during the second and third months.

    During the grace period applicable to You, You can avoid termination or nonrenewal of this Agreement by paying the full Premium payment You owe to Molina.

    If You do not pay the full Premium payment by the end of the grace period, this Agreement will terminate. You will still be responsible for any unpaid Premiums You owe Molina for the grace period if You receive advance payment of the premium tax credit.
    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? You may recover an over payment to Molina as a refund if you find that you paid too much. You may also seek a credit toward your next month’s premium, which might be easier.
    If you would like to recover an over payment to Molina, simply call the Member Services number located on your ID card, and explain the amount you are seeking and why you think you over paid Molina. We will be happy to help.
    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, 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.

    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? 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 15 days of receipt of the request.

    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 has a list of drugs that We will cover. The list is known as the Drug Formulary. You can determine if your prescription drug is on the Drug Formulary, by visiting www.molinamarketplace.com. You can also call Member Services and ask about whether a specific drug is covered.

    If your prescription drug is not listed on our Drug formulary, you or your participating provider may a request prior authorization review by contacting Molina Customer Support phone number identified on your ID Card and within the Provider Manual, to determine any access to clinically appropriate drugs that your doctor feels is best for you. The doctor will send to Molina a specially completed request form to let Molina know how the drug is medically necessary for your condition. If the request is approved, we will notify your doctor. If it is not approved, we will notify you and your doctor, including the reason why.

    There are two types of prior authorization requests for clinically appropriate drugs not covered under plan:

    Expedited exception request – this is for urgent circumstances that may seriously jeopardize your life, health, or ability to regain maximum function, or for undergoing current treatment using non-formulary prescription drugs .

    Standard exception request – this is for non-urgent circumstances

    Notification - following your request, you and/or your doctor will be notified of our decision no later than:
    • 24 hours following receipt of request for expedited exception request
    • 72 hours following receipt of request for standard exception request

    If your initial request is denied, you may seek additional review, as described in the agreement section on "Prescription Drug Coverage."
    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)? Coordination of benefits (COB) is the process for the order of payment when you may have health insurance under more than one insurer.

    COB governs 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.

    For a complete description of how cob works with your plan, consult your evidence of coverage, policy or certificate.
  •  Enrollment
    Why should I have health coverage? 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.
    What happens if I do not have health insurance? Without health insurance, you may suffer catastrophic financial losses due to illness or injury.
    What if I have a pre-existing medical condition? 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.
    When is Open Enrollment? Open enrollment for 2019 has ended. Individuals may qualify for enrollment outside of Open Enrollment through a Special Enrollment Period.

    Open enrollment for 2020 is November 1, 2019 through December 15, 2019.
    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:
    • 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
    • Change your place of residence
    • 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

    As a new member, when will my coverage start?
    • 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.
    When will I receive my Molina ID card? 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.
  •  Benefits
    How can I learn more about insurance coverage with Molina? Check out our Molina Marketplace Plans and other important Molina Marketplace information here. Or, simply Contact us to learn more. We can help you understand the right Molina plan options for you and your family.
  •  Billing
    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 select a Primary Care Provider? Upon enrolling and paying your first month’s premium, you will be asked to select a Participating Primary Care Provider for you and for any family members.
    How do I know which doctors I can see? To determine who might be best for you, go to the Provider Online Directory.
    Is my Pharmacy in your network? Molina participates with CVS Caremark Pharmacies. You will need to determine if your pharmacy is within our participating list of pharmacies by going to the online Pharmacy locator.
    Will my prescription drug be covered? You can search for whether your prescription drug is covered by Molina by going to the online Formulary (drug list).
  •  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 12/31/2019 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.

    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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