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”, 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. This payment may cover only a portion of the total cost sharing for the covered services that you receive. The participating provider will bill you for any additional cost sharing amounts that are due.

    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 agreement. However, you are responsible for paying charges for any health care services or treatments that are:
    • not covered services under this agreement, or
    • provided by a non-participating provider, except that Molina will cover 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”, and
    2. for exceptions described in the section of this agreement titled “What if There Is No Participating Provider to Provide a Covered Service?”

    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
    P.O. Box 22712
    Long Beach, CA 90801
    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.

    Routine prior authorization requests will be processed within 5 business days of receiving complete information from your doctor, and Molina will respond to prior authorization requests within 14 calendar days.

    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.

    You should consult your evidence of coverage, policy or certificate, 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 "Prior Authorization Request Form" and instructions for completing a request can be found here.

    Molina Marketplace
    Phone: (855) 322-4079
    Fax: (800) 961-5160

    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
  •  Benefits
  •  Billing
  •  Provider and Pharmacy Network
  •  Member Services
  •  Were you automatically enrolled to Molina from another insurance carrier?