Members

About Your Care

We want to give you good care!

Molina Healthcare (Molina) works with our providers to give you good health care. We look at your member benefits and make choices about care based on what you need. We want you to know:

  • We do not reward providers to deny care.
  • We do not reward staff or other people to deny care or give you less care.
  • We do not pay extra money to providers or our staff members to deny tests or treatments that you need to get better or stay healthy.

 

Members who have a concern about their health care can call Member Services:

  • Our staff are here to take calls Monday through Friday between 8 a.m. – 6 p.m. CT (except holidays). If members call after 6 p.m., they can leave a message and their phone number. Our staff will return the call in a timely manner, no more than one business day.
  • Staff is also available to accept collect calls.
  • There are nurses you can talk to about your health care choices and getting the needed care available through our Nurse Advice Line.
  • A bilingual staff member or interpreter is available for members.

 

Primary Care

A Primary Care Provider (PCP) is a doctor who helps you when you are sick and can also help you stay healthy. You may think you do not need a doctor until you are sick. This is not the best time for you to meet your doctor for the first time. Call your Primary Care Provider to make your first appointment. This first visit will help your PCP get to know you and help you stay well. Please call  Member Services if you need help getting an appointment.

Go to your PCP for:

  • Check-ups
  • Vaccines
  • Illnesses
  • Specialist visits
  • Hospital visits

Routine checkups help your PCP detect and treat medical conditions early. If you need to see a specialist, your PCP will refer you to one. Your PCP works with you to keep you and your family healthy.

Specialty Care

Your PCP will take care of most of your needs. There may be times when you will need to see a specialist. Your PCP will refer you to a specialist that can treat your specific condition. We call this a referral.

Examples of specialists are:

  • Cardiologists
  • ENT physicians (Ear, Nose & Throat)
  • Neurologists
  • Allergists

There are some providers that do need referrals. For example:

  • Gynecologists
  • Dermatologists
  • Psychologists

It is a good idea to check with Member Services to see if the provider is in Molina’s network. You can also use our provider look-up tool., If you need to see a provider or specialist that is not in Molina’s network, call your PCP to get prior approval from Molina.

Out of Network Services

If a Molina provider is unable to provide a member with necessary and covered services, Molina must cover the needed services through an out-of-network provider. The cost to members should be no greater than it would be if the provider were in Molina ’s network. This must be done in a timely manner for as long as Molina is unable to provide the service.

After Hours Care

If you need care after normal business hours, call your PCP. All PCPs have coverage for their patients 24 hours a day, 7 days a week. Your PCP may have an answering service where someone can help you with your medical issue or they can call your PCP to discuss your options for care. Sometimes yourPCP may have another PCP cover for them either after hours or if your PCP is out of the office. They could give you advice over the phone and sometimes prescribe a medication. You might be asked to visit the PCP or be sent to an urgent care center.

Molina also has a Nurse Advice Line with highly trained nurses. They can help you decide if you or your child should seek medical attention right away. You can call the Nurse Advice Line at 844-782-2721 and talk to a nurse.24 hours a day, 7 days a week.

If you feel this is an emergency, call 911 or go to the nearest emergency room.

Emergency Care

An emergency is a medical problem that needs to be treated immediately. We cover emergencies wherever you are. You do not have to call Molina for approval in an emergency. Call 911 or go to the nearest emergency room. This includes a facility that is not part of Molina. You can get emergency care 24 hours a day, 7 days a week.

Some examples of emergency are:

  • Miscarriage or pregnancy problems
  • Seizures or convulsions
  • Unusual or excessive bleeding
  • Unconsciousness
  • Overdose/Poison
  • Severe pain
  • Severe burns
  • Trouble breathing
  • Chest pains

Please carry your Member ID Card with you. If you are told you need to stay in the hospital, make sure the hospital calls Molina. If you are asked to stay in a hospital that is not part of Molina’s network, we will transfer you to a hospital that is part of Molina‘s network as soon as you are well enough to be moved. If the emergency room doctor decides that you do not have to stay but you decide to stay, you may be responsible for the cost of your stay. Once you leave the ER and are instructed to follow up with your PCP, please schedule an appointment with your PCP. If you need help scheduling an appointment, please contact Member Services.

If you are not sure if you need emergency care, call your PCP or call our 24-Hour Nurse Advice Line toll-free. The Nurse Advice Line is staffed by registered nurses (RNs). You can call the Nurse Advice Line 24 hours a day, 7 days a week.

Hospital emergency rooms are only for real emergencies. These are not good places to get non-emergency care. They are often very busy and must care first for those whose lives are in danger. Please do not go to a hospital emergency room if your condition is not an emergency.

Out of Area Care

If you are away from Molina ’s service areas and need emergency care, go to the nearest emergency room for care. Please contact Molina within 24 hours or as soon as you can. When you are away from Molina ’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.

Urgent Care

Urgent care services are for conditions that need attention right away. You should call your PCP for urgent care services. Your PCP may send you to an after-hours clinic or an urgent care center when the PCP’s office is closed.

Some examples of urgent services are:

  • Minor injuries
  • Minor illnesses
  • High fever for children or elderly
  • Simple fractures
  • Flu
  • Eye injuries
  • Insect bites

An urgent care center is not an emergency room. If you are not sure if you need to go to the ER, call your PCP or Molina ’s 24-hour Nurse Advice Line. Your PCP or our nurses can help you decide what to do. You can find the number to our 24-Hour Nurse Advice Line toll-free here.

Second Opinions

You have the right to request a second opinion from a qualified health care professional within Molina’s network or we can arrange for you to obtain one outside of our network at no cost. Please contact  Member Services to request the second opinion.

If the request is urgent and serious:

  • Molina 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.

Language Assistance

Interpreter services are free to all members. To ask for an interpreter, please contact Member Services. Interpreter can help you:

  • Make an appointment.
  • Talk with your doctor or nurse.
  • Get emergency care.
  • File a complaint, grievance, or appeal.
  • Get help from a pharmacist about taking medicine.

Interpreter services are free to all members. To ask for an interpreter, call Member Services.

If you have an appointment, your doctor can help you find an interpreter.

If you are hearing or sight impaired, Molina can help you. It may take some time, please do not hang up.

  • We offer our Member Handbook in braille. Please contact Member Services to request one.
  • If you are hard of hearing, call our TTY line at 711.