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Annual Notice of Change (ANOC): The Annual Notice of Changes (ANOC) is a brief summary of benefits and benefit changes to your plan. For a more comprehensive description of your benefits, please refer to the Evidence of Coverage (EOC) below.

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP) H8716-004-001-A

2026 Molina Medicare Complete Care Plus (HMO D-SNP) H8716-004-001-B

2026 Molina Medicare Complete Care Plus (HMO D-SNP) H8716-004-002-A

2026 Molina Medicare Complete Care Plus (HMO D-SNP) H8716-004-002-B

Summary of Benefits: a summary of what we cover and what you pay. For a complete list of covered services and exclusions, refer to your Evidence of Coverage below.

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP) H8716-004-001

2026 Molina Medicare Complete Care Plus (HMO D-SNP) H8716-004-002

Click on the links below to access important member forms.

 

Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

 

Appointment of Representative Form (CMS-1696)

 

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina Medicare at:

 

Molina Medicare
7050 Union Park Center, Suite 600
Midvale, UT 84047

Coverage Determination Request Form  – Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy.

 

You may submit your Coverage determination request form here online.

 

You may also complete the below form and mail or fax.

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

 

Complete this form and mail or fax to:

 

Address:		7050 Union Park Center, Suite 600 Midvale, Utah 84047
Fax:		(866) 290-1309

How to Request a Redetermination  - Please read this document to understand what you need to do to request an appeal

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

Redetermination Form  - Use this form to request a redetermination (appeal).

 

You may submit your Redetermination request form here online.

 

You may also complete the below form and mail or fax.

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

 

Address:		7050 Union Park Center, Suite 600 Midvale, Utah 84047
Fax:		(866) 290-1309

 

Direct Member Reimbursement Form - Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

 

Grievance and Appeal forms & the Medicare.gov Complaint Form

Advance Directives Information Sheet: provides insight on Advance Directives.

 

Advance Directives Information Sheet

 

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

 

If you qualify for extra help, Low Income Subsidy (LIS), to pay for your prescription drug costs, Medicare could also pay 75% or more of your Plan Premium, annual deductibles and co-insurance (if applicable).

 

Additionally, those who qualify won’t have a coverage gap or a late enrollment penalty.

 

To qualify in 2026, your yearly income is limited to $16,590 for an individual or $33,100 for a married couple living together.

 

If your income and resources are slightly higher, you should still apply. You may still qualify if you meet one of the following conditions:

• You or your spouse support other family members who live with you.
• You or your spouse have earnings from work.
• You or your spouse live in Alaska or Hawaii.

 

If you currently have an Employer/Union health plan or a State Pharmacy Assistance Program (SPAP) it will not affect the help you receive paying for the prescription drugs.

 

The above charts show you what your monthly plan premium will be if you get this subsidy. The premiums listed above include both your medical and prescription drug coverage.

 

If you aren't getting extra help, you can see if you qualify by calling Member Services.

 

Additionally, you may verify the details of qualification for extra help as well as review more information on extra help at the Centers for Medicare and Medicaid Services (CMS) website.

 

You may also call the following organizations to see if you qualify:

• Medicare: (800) Medicare or (800) 633-4227, TTY: (877) 486-2048, 24 hours a day, 7 days a week.
• Social Security Administration: (800) 772-1213, TTY: (800) 325-0778, 7 a.m. - 7 p.m., Monday to Friday.

 

 2026 OTC Product Catalog

 

Visit NationsOTC.com/Molina

 

You will receive your Member ID Card after your enrollment is confirmed

 

While you are a member, you must use your membership card whenever you get any services covered by this plan. It is also to be used for prescription drugs you get at network pharmacies.

 

If your plan membership card is damaged, lost, or stolen, you can request for a new card on your My Molina portal.

 

 

This report shows how prior authorization requests are handled, such as how many were approved or denied and how quickly decisions were made. To find out if a specific service needs prior authorization, members and providers should check the plan’s Prior Authorization Guide or use the Prior Authorization Lookup Tool.

Prior Authorization Guide

Prior Authorization Lookup Tool

H2533 Prior Authorization Report 2025

Prior Authorization Statistics Molina Healthcare Inc Percentage The percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services. 91% The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 9% The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 56% The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 77% The percentage of STANDARD prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 0% The percentage of EXPEDITED prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 100% The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 95% The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 5% Timing Average time that elapsed between the submission of a request and a determination by the payor, plan or issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 3 Median time that elapsed between the submission of a request and a determination by the payor, plan, issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 2 Average time that elapsed between the submission of a request and a decision by the payor, plan or issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 17 Median time that elapsed between the submission of a request and a decision by the payor, plan, issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 18

H8176 Prior Authorization Report 2025

Prior Authorization Statistics Molina Healthcare Inc Percentage The percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services. 94% The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 6% The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 75% The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 100% The percentage of STANDARD prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. NA The percentage of EXPEDITED prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. NA The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 88% The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 13% Timing Average time that elapsed between the submission of a request and a determination by the payor, plan or issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 2 Median time that elapsed between the submission of a request and a determination by the payor, plan, issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 1 Average time that elapsed between the submission of a request and a decision by the payor, plan or issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 13 Median time that elapsed between the submission of a request and a decision by the payor, plan, issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 7