We want to give you good care!
We work 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 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
If you have a concern about your health care, call Member Services. If you call after our regular business hours, 8 am to 8 pm, Monday to Friday, please leave a message and we will return your call within the next business day.
- Our staff can accept collect calls
- You can talk to our nurses about care choices and getting care through our 24-Hour Nurse Advice Line
- A bilingual staff member or interpreter is available for members
See your Primary Care Provider (PCP) for a health checkup. Many people wait until they are very sick to see a provider. You do not need to wait. Make sure you schedule a checkup before you get sick. This will help keep you well.
A Primary Care Provider (PCP) can handle most health care needs. But sometimes there are special problems such as a broken bone or heart disease. A visit to a provider who has extra training may be needed. This provider is called a specialist. If members need to see a specialist, their PCP will make sure they see the right one and may be able to help them get an appointment faster.
Out of Area Care
Routine care is not covered outside the Molina Dual Options service area, unless members are seen by a Molina Dual Options participating provider. If members need special care by a provider who is not part of the Molina Dual Options network, their PCP will help to get the authorization (approval) that is needed.
If members travel outside the service area, Molina Dual Options pays for emergency care. Members may go to a local emergency room (ER) or an urgent care clinic. Members need to tell them that they are a Molina Dual Options member and show them their Molina Dual Options ID card. Remember that routine care is not covered outside the Molina Dual Options service area.
Out of Network Coverage and Services
As a new Molina Dual Options Healthy Connections Prime member, you may continue to see your physicians or receive services that were authorized before you joined Molina Dual Options Healthy Connections Prime for 180 days. Molina Dual Options Healthy Connections Prime will attempt to contract with your provider during this time. This time period is determined by CMS or South Carolina.
You may also receive care from an out-of-network provider (a provider who is not part of our plan's network) in the following cases:
- The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Chapter 3 of the Member Handbook.
- If you need medical care that our plan covers and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. In this case prior authorization is required. In this situation with a prior authorization, we will cover these services as if you got the care from a network provider. However, if you obtain routine care from out-of-network providers without prior authorization, neither Medicare, South Carolina Healthy Connections Medicaid nor the plan will be responsible for the costs.
- Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.
Most other services out-of-network are not covered. If you have questions about out-of-network coverage and services, please call Member Services.
After Hours Care
There may be times when members need care and their Primary Care Provider (PCP) is closed. If it is after hours and the PCP's office is closed members can call the 24-Hour Nurse Advice Line. Nurses are available to help you 24 hours a day, 7 days a week.
Emergency care is for sudden or severe problems that need care right away. It can also be care that is needed if your life or health is in danger. Emergency care is a covered benefit for members. If a member needs emergency care, they can call 911 or go to the nearest hospital. They do not needs prior approval. If members have an urgent matter that does not threaten you life, they can also call the Nurse Advice Line, 24 hours a day, 7 days a week. If you desire, there is also a Spanish Nurse Advice Line.
Members who do not agree with a provider's plan of care have the right to a second opinion from another Molina Dual Options provider or from an out-of-network provider. This service is at no cost to the member.
Members have the right to an interpreter. There is no cost. Members should tell the office staff if they would prefer to talk in their own language. If you need assistance, call Member Services.
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-735-5831 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-735-5831 (TTY: 711).
ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 5831-735-855-1 (رقم هاتف الصم والبكم.(711 :