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? Molina Healthcare of New Mexico may not restrict you or your eligible dependents who are enrolled in this policy from seeking medical treatment with a non-participating provider. However, should you or your eligible dependents who are enrolled in this policy obtain medical treatment with a non participating provider You will be 100% responsible for payment and the payments will not apply to your deductible or annual out-of-pocket maximum for any of these services.For exceptions please review the following sections of the Agreement titled “Emergency Services and Urgent careservices”, and “What if There Is No Participating Provider to Provide a Covered Service?.”

    EMERGENCY AND URGENT CARE SERVICES

     

    What is an Emergency?
    Emergency care means health care procedures, treatments, or services delivered to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in:

    • Placing the patient’s health in serious danger.
    • Serious damage to bodily functions.
    • Serious dysfunction of any bodily organ or part.
    • Disfigurement to the person;
    • Or a condition in which a reasonable person believes that immediate medical attention is required.

    Urgent Care
    If You are within Molina’s service area you can ask your PCP what participating provider urgent care center to use. It is best to find out the name of the participating provider urgent care center ahead of time. Ask Your doctor for the name of the Participating Provider urgent care center and the name of the hospital that You are to use.If You are outside of Molina’s Service Area, and You need urgent care You may go to the nearest emergency room.You have the right to interpreter services at no cost. To help in getting after hours care call toll-free at 1 (888) 665-4621. Urgent care services are subject to the cost sharing. Please be aware that if you go to a non-participating provider, You will be 100% responsible for payment and the payments will not apply to your deductible or annual out-of-pocket maximum for any of these services.
    How are claims for covered medical services submitted for payment under my plan? Notice of Claim
    Written notice of a member’s claim relating to covered services under this EOC, when applicable (a “claim”) must be given to Molina Healthcare within 20 days after the claim for reimbursement or payment of covered services under this EOC becomes owing, or as soon thereafter as is reasonably possible. Notice of the claim given by or on behalf of the member to Molina Healthcare at the following address, with information sufficient to identify the member and the nature of the claim, shall be deemed notice to Molina Healthcare:
    Molina Healthcare P.O. Box 22801 Long Beach,CA 90802
    Upon your submission of a claim to Molina Healthcare, Molina will calculate the amount of the claim that may be due to you in accordance with this agreement and applicable state and federal laws. If amounts subject to the claim are owing to you, such amounts may be reduced by applicable cost sharing.

    Claim Forms
    Molina Healthcare, upon receipt of a notice of claim from a member as provided above, will furnish to the member such forms as are usually furnished by Molina Healthcare for filing proofs of loss (if such additional forms are appropriate and required by Molina) with respect to such claims. If Molina Healthcare does not furnish such required forms to the member within 15 days after the notice of claim has been given to Molina, the member shall be deemed to have complied with the requirements of this EOC as to proof of loss upon submitting, within the time fixed by this EOC for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is being made.
    Proof of Loss
    If required or appropriate as determined by Molina Healthcare, written proof of loss relating to a claim must be furnished to Molina at its office (identified in the “Notice of Claim” section above) within 365 days after the occurrence or start of the loss on which the claim is based to validate and preserve the claim. If written proof of loss is not given within that time, the claim will not be invalidated, denied or reduced if it is shown that written proof of loss relating to a claim was given as soon as was reasonably possible or legal incapacity of the member extended the time period for providing such proof of loss. Foreign claims and proof of loss relating to such claims must be translated in U.S. currency prior to being submitted to Molina Healthcare.
    Time of Payment of Claims
    Upon the timely receipt of the proof of loss (if required by Molina Healthcare) and all other information necessary to evaluate, process and pay a claim under this EOC, Molina Healthcare will pay the claim within 60 days after receipt of such proof of loss and other information. Payment of claims by Molina requires that documentation, however submitted to Molina, be in form and content reasonably acceptable to Molina and contain all required information for processing without the need for additional information from outside of Molina Healthcare. Interest penalties will not be applied to claims not paid within the timeframes stated.
    What is my grace period?
    • If you do not receive advance payment of the premium tax credit, Molina Healthcare will give you a ten thirty-one (31) 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 thirty-one (31) 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.
    Retroactive denial of claims does not apply to services that Molina has pre-authorized.
    .
    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 which 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 Molina’s Medical Directors 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 a prior approval.

    Routine prior authorization requests will be processed within 5 business days. This is 5 days from when we get the information we need and ask for. We need this information to make the decision. It may take up to 14 calendar days from the receipt of the request. We will deny prior authorization requests if you do not provide the information we requested.

    We process prior authorizations for medical conditions that may cause a serious threat to your health within 24 hours. This is 24 hours from when we get the information we need and ask for. We need this information to make the decision.

    We will deny a prior authorization if information we request is not provided to us. The time required may be shorter under Section 2719 of the federal Public Health Services Act and subsequent rules and regulations. Molina processes requests for urgent specialty services right away. This is done by phone.

    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.
    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.

    The pharmacy "New Mexico Prior Authorization Form" and instructions for completing the request can be found here.

    Molina Marketplace Phone:
    (855) 322-4078
    Fax: (866) 472-4578

    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.
  • 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 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 or 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 size or household size.
    • Have a change in disability status
    • You lose your health coverage, including no longer being eligible for Medicaid, or losing your coverage through your job, or exhausting your COBRA coverage
    • 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.
  • 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 My Molina 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 My Molina 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

    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