Frequently Asked Questions
- 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:
- for emergency services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,”
- for exceptions described in the section of the Agreement titled “What if There Is No Participating Provider to Provide a Covered Service?,” and
- 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 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 Florida, Inc.
8300 NW 33 St., Suite 400,
Doral, FL 33122
1 (888) 560-5716
What is my grace period?
- If you do not receive advance payment of the premium tax credit, Molina Healthcare will give you a ten (10) calendar-day grace period before cancelling or non renewing your coverage due to failure to pay your premium. Molina will continue to provide coverage pursuant to the terms of this agreement, including paying for covered services received during the ten (10) calendar-day grace period. During the grace period, you can avoid cancellation or nonrenewal by paying the premium you owe to Molina If you do not pay the premium by the end of the grace period, this agreement will be cancelled at the end of the grace period. 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, Molina will give you a three (3) month grace period before cancelling or not renewing your coverage due to failure to pay your premium. Molina will pay for covered services received during the first month of the three-month grace period. If you do not pay the premium by the end of the first month of the three-month grace period, your coverage under this plan will be suspended and Molina will not pay for covered services after the first month of the grace period until we receive the delinquent premiums. If all premiums due and owing are not received by the end of the three-month grace period, this agreement will be cancelled effective 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.
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 of premium to Molina? 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. What is Medical Necessity? 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. What is a 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, 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. 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.
What is an Explanation of Benefits (EOB)? 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. What is Coordination of Benefits (COB)? 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.
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 2020 has ended. Individuals may qualify for enrollment outside of Open Enrollment through a Special Enrollment Period.
Open enrollment for 2021 is November 1, 2020 through December 15, 2020.
What is a Special Enrollment Period 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.
As a new member, when will my coverage start?
- If You apply on or before December 15, 2020, the Effective Date of Your coverage is January 1, 2021.
- Applications made after December 15, 2020 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.
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.
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 12/31/2020 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
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