Will I be responsible for any out of pocket costs billed by a Non-Participating (Out
of Network) Provider?
PLEASE NOTE: Urgent Care is not covered if a member is treated by a non-participating
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
1) for Emergency Services in accordance with the section of the Agreement titled
“Emergency Services and Urgent Care Services”, and
2) for exceptions described in
the section of this Agreement titled “What if There Is No Participating Provider
to Provide a Covered Service?,”
How are claims for covered medical services submitted for payment under my plan?
In most cases, Participating Providers will ask You to make a payment toward Your
Cost Sharing at the time You check in. Keep in mind that this payment may cover
only a portion of the total Cost Sharing for the Covered Services You receive. The
Participating Provider will bill You for any additional Cost Sharing amounts that
The Participating Provider is not allowed to bill You for Covered Services You receive,
other than for Cost Sharing amounts that are due under this Certificate. However,
You are responsible for paying charges for any health care services or treatments
1. not Covered Services under this Certificate, or
2. provided by a Non-Participating Provider.
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. If the bill is for a prescription, you will need to include a copy of the prescription label.
Mail this information to the following address:
P.O. Box 22668
Long Beach, CA 90801
Or you can call Member Services with any questions: (888) 560-4087
What is my grace period?
- If You do not receive advance payment of the premium tax credit: A grace period
of 31 days will be granted for the payment of each premium falling due after the
first premium, during which grace period the policy shall continue in force. Molina
will process payment for Covered Services received during the 31 day grace period.
You will be responsible for any unpaid Premiums You owe Molina Healthcare for the
- If You receive advance payment of the premium tax credit: A grace period of 3 months
will be granted for the payment of each premium falling due after the first premium,
during which grace period the policy shall continue in force.
- Molina will process payment for Covered Services received during the first month
of the grace period. You will be responsible for any unpaid Premiums You owe Molina
Healthcare for the first month of the grace period.
- Molina will hold payment for Covered Services received after the first month of
the grace period until We receive the delinquent Premiums. If Premiums are not received
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.
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 your doctor is a Participating (In-Network) Provider.
How do I recover an overpayment to Molina?
If You believe that We have not paid a claim properly, You should first attempt
to resolve the problem by contacting us. Follow the steps described in the "Complaints"
section, below. If You are still not satisfied, You may call the Michigan Department
of Insurance and Financial Services DIFS for instructions on filing a consumer complaint.
Call 1 (877) 999-6442 or visit the Department’s website at http://www.michigan.gov/difs/0,5269,7-303-12902_12907---,00.html
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, amount, frequency,
level, 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 by Molina that confirms that a requested health care service,
treatment plan, prescription drug or item of durable medical equipment has been determined to be Medically Necessary
and is covered under Your plan. A prior authorization is not a guarantee of claim payment. 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.
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 Healthcare has a list of drugs that We will cover. The list is known as the
Drug Formulary. The drugs on the list are chosen by a group of doctors and pharmacists
from Molina Healthcare and the medical community.
The group meets every 3 months to talk about the drugs that are in the Drug Formulary.
They review new drugs and changes in health care, in order to find the most effective
drugs for different conditions. Drugs are added to or removed from the Drug Formulary
based on changes in medical practice and medical technology. They may also be added
to the Drug Formulary when new drugs come on the market.
You can look at Our Drug Formulary on Our Molina Healthcare website at MolinaMarketplace.com.
call Molina Healthcare and ask about a drug. Call toll free 1 (888) 560-4087, Monday
through Friday, 8:00 a.m. through 5:00 p.m. ET. If You are deaf or hard of hearing,
call toll-free 1 (888) 665-4629 or dial 711 for the Telecommunications Relay Service.
Access to Drugs That Are Not Covered
Molina Healthcare has a list of drugs that We will cover. The list is known as the Drug Formulary.
The drugs on the list are chosen by a group of doctors and pharmacists from Molina Healthcare and the medical community.
- You can ask your physician to order a similar drug that is listed in the formulary.
- You can ask your physician to request an exception so your non-formulary drug can be covered by your benefit.
- You can start the request for exception for a non-formulary drug. If you want to start the exception process, you can call Member Services or complete the form below.
Member Exception Form
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 request is denied, you may still seek review through independent review organization (IRO) review.
Consult your evidence of coverage, policy or certificate for more information.
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)?
This Coordination of Benefits (“COB”) provision applies when a person has health
care coverage under more than one Plan. For purposes of this COB provision, Plan
is defined below.
The order of benefit determination rules govern 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