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,”
    2. for out-of-area urgent care services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,” and
    3. for exceptions described in the section of the 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? Once you have obtained covered services from a participating provider, the provider is responsible for submission of claims to Molina for determination of payment under your plan. You are not responsible for submitting claims to Molina for payment of benefits under your plan.

    However, 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 of South Carolina, Inc.
    Customer Support
    PO Box 40309
    North Charleston, SC 29423
    1 (855) 885-3176
    What is my grace period?
    • If you do not receive advance payment of the premium tax credit, Molina Healthcare will give you a 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.
    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 2 business days of receiving complete information from your doctor.

    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 "Universal Prior Authorizations Medications Form" and directions for completing the request can be found here.

    Molina Marketplace
    Member Services: (855) 885-3176
    Provider Services: (855) 237-6178
    Fax: (855) 571-3011

    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
  • Provider and Pharmacy Network
    How do I know which providers I can go to? To view the providers available in your network, visit the Provider Online Directory.
    How do I select a Primary Care Provider (PCP)? You can select a Primary Care Provider (PCP) once your coverage is effective with the plan. You can register for your My Molina online member account and select a Primary Care Provider (PCP) of your choice.

    If you are having trouble, contact us and we can help.
    How do I change my primary care physician (PCP)? You can change your Primary Care Provider (PCP) through your secure My Molina online member account. You can also call the toll-free number on your ID card and follow the menu options.
    What happens if my PCP leaves the network? If your doctor leaves the network, you will need to select another Molina participating provider, refer to our provider online directory to view doctors and hospitals.

    Under limited circumstances, you may be able to continue with your PCP for continuation of coverage as described in the Agreement.

    Please contact us for more information.
    How do I know what pharmacies to go to? Your pharmacy network is through CVS. You can see which pharmacies are available to you. Go to the 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). This information is also available in your My Molina online member account.
  • Billing
    How will my premiums be impacted if I am eligilbe for APTC? If you are eligible for premium assistance (Premium Tax Credits), you could save even more money. Contact the Marketplace in your state, so that you get the right Premium Tax Credit you may be able to receive. Please go to Healthcare.gov and update your information.
    I have an issue with my auto-payment. What should I do? Please visit your Auto Pay account in your My Molina online member account located here.

    If you are having trouble, contact us and we can help
    Can I set up an auto-payment? Yes, it is easy to do so by setting up your My Molina online member 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 online member account.
    When will my auto-payment be taken from my account? Auto-payments will be deducted on the 23rd of the month, or the next banking day if the 23rd is a holiday or weekend, for the total balance due of your health insurance premiums.

    This remains in effect for as long as you are covered with Molina, or until you cancel AutoPay, whichever comes first.
    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 online member account to find out your balance, or call the customer support number located here.
  • Member Services
    I enrolled in a Molina plan. When can I register on the "My Molina" online member portal to see my benefits and services? You can register on the My Molina online member portal once your initial payment is processed and you become effective with the plan.
    How can I get a new or replacement ID card? Once we receive your initial payment, you will receive your new ID card in the mail within 5-7 business days.

    If you need a replacement or additional ID card, you can view and print one within your secure My Molina online member account.

    Go to MyMolina.com and register your personal online member account today!

    If you are having trouble, contact us and we can help
    What is a My Molina online member account and what can I do with it? Your My Molina online member account is a powerful tool that puts you in control of your health coverage. It’s easy to set up and lets you manage your account wherever you are on a computer or your smart phone.

    Use your My Molina online member account anytime to conveniently do things like:
    • Access your digital ID card and download view it ton your smart phone, or print it or request a new ID card to be sent to your current address on file with Molina
    • Choose or change your Primary Care Physician (PCP)
    • View Billing Information
    • Make a Payment
    • Sign up for automatic monthly payment through AutoPay
    • Check to see if we cover your prescription drugs
    • Quick links to benefit coverage and much more!

    Go to MyMolina.com and register your personal online member account today!
    How do I set up My Molina online member account? Setting up your My Molina online member account is easier than ever- it only takes a few minutes.

    Go to MyMolina.com and complete a few simple steps to register. Be sure to have your Member ID number, Date of Birth, and State where you are enrolled.
    How can I access My Molina online member account on my smart phone? MyMolina.com can be accessed by your desktop or mobile device.

    You can download “Molina Mobile” from your app store using your smart phone.

    Molina Mobile is a self-service mobile application for Molina members. Molina Mobile has many features and will allow you to have the same access as your My Molina online member account.
    Does Molina offer Telehealth or Telemedicine Services? Yes. For more information or to create an account, visit the Virtual Care page.

    To view your specific benefit coverage, visit your My Molina online member account.
  • Were you automatically enrolled to Molina?