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Become a Member

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? PLEASE NOTE: Urgent Care is not covered if a member is treated by a non-participating provider!
    You must receive covered services from participating (in-network) providers in order for those service to be a covered service under your plan.

    Services provided by non-participating (out-of-network) providers without being prior authorized by Molina are not covered services, and you will be 100% responsible for payment to non-participating providers, and the payments will not apply to any applicable deductible or annual out-of-pocket maximum under your plan.

    Exceptions -
                                   
    Emergency Services:
    • Emergency services obtained for treatment of an emergency medical condition within or outside of the service area of your plan are considered covered services without prior authorization, subject to payment of the applicable cost share under your plan.
    • Some hospital-based providers who may be involved in your emergency care (such as emergency room, radiology, anesthesiology, or pathology providers), may not contract as participating providers.
    • In this case, these non-participating hospital based providers, must accept payment of the covered expense provided by Molina and are prohibited from balance billing you beyond the applicable cost share under your plan.

    Urgent Care Services:

    Within the service area of your plan –
    • Participating providers – urgent care services do not require prior authorization. However within the service area, you must access participating urgent care providers in order for those services to be a covered service under your plan. You will only be liable for the urgent care cost share under your plan.
    How are claims for covered medical services submitted for payment under my plan? While most claims for payment of Covered Services will be submitted directly by Your Participating Providers, You may incur charges for Covered Services can be submitted by You as a claim to Molina Healthcare. For example, you may have received Emergency Services from a non-Participating Provider.
    With the exception of any required Cost Sharing amounts (such as a Copayment or Percentage Cost Sharing), if You have paid for a Covered Service or prescription that was approved or does not require approval, Molina Healthcare will pay You back. You will need to mail or fax us a copy of the bill from the doctor, hospital, or pharmacy and a copy of Your receipt. If the bill is for a prescription, You will need to include a copy of the prescription label. Mail this information to Molina Healthcare’s Customer Support Center: PO Box 22719, Long Beach, CA 90801, or you call Member Services with any questions: (888) 560-2025 (TTY/TTD: 711).
    You must provide us with notice of a claim within 20 days following the date of service, unless it is not reasonably possible to do so. Failure to give notice within this time will not invalidate or reduce any claim if You show that it was not reasonably possible to give the notice, and that the notice was given as soon as it was reasonably possible. Within 15 days following Our receipt of the notice of claim, We will acknowledge the receipt of the claim, begin Our investigation of the claim, and request any additional items, statements, and forms that We reasonably believe will be required from You. All claims must be properly submitted within 90 days of the date that You receive the services or supplies. Claims not submitted and received by Molina Healthcare within twelve (12) months after that date will not be considered for payment of benefits except in the absence of legal capacity.
    What is my grace period?
    • 30-day grace period to pay the full Premium payment due if You do not receive advance payment of the premium tax credit. Molina will process payment for Covered Services received during the grace period. You will be responsible for any unpaid Premiums You owe Molina Healthcare for the grace period; or
    • Three month grace period to pay the full Premium payment due if You receive advance payment of the premium tax credit. Molina will hold payment for Covered Services received after the first month of the grace period until We receive the delinquent Premiums. If Premiums are not received by the end of the three-month grace period, You will be responsible for payment of the Covered Services received during the second and third months.
    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 to Molina? You may recover an over payment to Molina as a refund if you find that you paid too much. You may also seek a credit toward your next month’s premium, which might be easier.

    If you would like to recover an over payment to Molina, simply call the Member Services number located on your ID card, and explain the amount you are seeking and why you think you over paid Molina. We will be happy to help.
    What is Medical Necessity? “Medically Necessary” or “Medical Necessity” means health care services determined by a provider, in consultation with Molina Healthcare, to be clinically appropriate or clinically significant, in terms of type, frequency, event, site, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by Molina Healthcare consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical, behavioral, or mental health condition, illness, injury, or disease.

    Routine Prior Authorization requests will be processed within five business days. This is five 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.
    What is Prior Authorization, and how does it impact services under my plan? A Prior Authorization is an approval by Molina that 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. A prior authorization is not a guarantee of claim payment. 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.
    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 Healthcare has a list of drugs that it will cover. The list is called the Drug Formulary. The drugs on the list are chosen by a group of doctors and pharmacists from Molina Healthcare and the medical communMolina Healthcare has a list of drugs that We will cover. The list is known as the Drug Formulary. The drugs on the list are chosen by a group of doctors and pharmacists from Molina Healthcare and the medical community.

    The group meets every 3 months to talk about the drugs that are in the Drug Formulary. They review new drugs and changes in health care, in order to find the most effective drugs for different conditions. Drugs are added to or removed from the Drug Formulary based on changes in medical practice and medical technology. They may also be added to the Drug Formulary when new drugs come on the market.

    You can look at Our Drug Formulary on Our Molina Healthcare website. The address is www.MolinaMarketplace.com. You may call Molina Healthcare and ask about a drug. Call toll free 1 (888) 560-2025. We are here Monday through Friday, 8:00 a.m. through 6:00 p.m. CT. If You are deaf or hard of hearing, call Our TTY line. You may dial 711 for the Telecommunications Service.

    Access to Drugs Which Are Not Covered
    Molina has a process to allow You to request clinically appropriate drugs that are not covered under Your product. Your doctor may order a drug that is not in the Drug Formulary that he or she believes is best for You. Your doctor may contact Molina’s Pharmacy Department to request that Molina cover the drug for You. If the request is approved, Molina will contact Your doctor. If the request is denied, Molina Healthcare will send a letter to You and Your doctor. The letter will explain why the drug was denied
    You may be taking a drug that is no longer on Our Drug Formulary. Your doctor can ask Us to keep covering it by sending Us a Prior Authorization request for the drug. The drug must be safe and effective for Your medical condition. Your doctor must write Your prescription for the usual amount of the drug for You. Molina may cover specific non-Drug Formulary drugs under the following conditions:
    • When Your doctor documents in Your medical record and certifies that the Drug Formulary alternative has been ineffective in the treatment of the Member’s disease; or
    • When the Drug Formulary alternative causes or is reasonably expected by the prescriber to cause a harmful or adverse reaction in the Member. When the Drug Formulary alternative causes or is reasonably expected by the prescriber to cause a harmful or adverse reaction in the Member.
    There are two types of requests for clinically appropriate drugs that are not covered under Your product:
    • Expedited Exception Request for urgent circumstances that may seriously jeopardize life, health, or ability to regain maximum function, or for undergoing current treatment using non-Drug Formulary drugs.
    • Standard Exception Request.
    You and/or Your Participating Provider will be notified of Our decision no later than:
    • 24 hours following receipt of request for Expedited Exception Request
    • 72 hours following receipt of request for Standard Exception Request
    If initial request is denied, You and/or Your Participating Provider may request an IRO review. You and or Your Participating Provider will be notified of the IRO’s decision no later than:
    • 24 hours following receipt of request for Expedited Exception Request
    • 72 hours following receipt of request for Standard Exception Request
    What is an Explanation of Benefits (EOB)? An explanation of benefits (EOB) is a statement Molina sends to you to explain what medical treatments and / or services Molina paid for on your behalf, the amount of the payment, and your financial responsibility pursuant to the terms of your policy. Molina will send you an EOB after you receive services from your doctor or a hospital.

    In some instances there may be one or more reasons why payment or partial payment cannot be made. If your claim has been denied and you believe that additional information will affect the processing of the claim, or you have a question about a covered service, a provider, your benefits or how to use your plan, you can contact member services to answer any questions you may have.

    Here are some of the definitions of the terms used in the EOB:

    • Procedure code - code number of the service that was performed.
    • billed amount - the amount of billed charges received from your provider for services rendered
    • Allowed amount - the amount the health plan pays for services rendered
    • Copay amount - the amount of your copay for certain benefits (i.e. office visit, ER, etc.). This is a fixed dollar amount.
    • Co-insurance amount – the amount owed by you after your deductible is applied. This is based on a percentage dictated by your benefit coverage.
    • Deductible amount - the amount applied toward your annual deductible, based on benefit coverage and claim.
    • Plan payment - the amount the health plan paid to the provider.
    • Remark code – additional messages that may explain how your claim was processed under "explanations of claims handling"
    • Total patient responsibility for this claim - the amount you owe the provider.
    • Description of remark code - explanation of the claim payment or denial.
    • Family out of pocket & deductible totals - a summation of your family's total yearly deductible amount and out of pocket amount based on your benefits, the year to date total that has been applied, and the remaining balances.
    What is Coordination of Benefits (COB)? The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one plan. Plan is defined below.
    The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits in accord with its EOC terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. The secondary plan may reduce the benefits it pays so that payments from all plans equal 100 percent of the total allowable expense. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the person has health care coverage under more than one plan. When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan's benefits. When this plan is secondary, it determines its benefits after those of another plan and may reduce the benefits it pays so that all plan benefits equal 100 percent of the total allowable expense.
  •  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 2018 has ended. Individuals may qualify for enrollment outside of Open Enrollment through a Special Enrollment Period.

    Open enrollment for 2019 is November 1, 2018 through December 15, 2018.
    What is a Special Enrollment Period Conditions that 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:

    • Not aware of penalty for not having health insurance (specific dates apply)
    • Getting Married or divorced
    • Have a child, adopt a child, or place a child for adoption
    • Have a change in income
    • Get Health coverage thorough a job or a program like Medicare or Medicaid
    • Change your place of residence
    • Have a change in disability status
    • Gain or lose a dependent
    • Become pregnant
    • Experience other changes that may affect your income and household size

    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, 2018, the Effective Date of Your coverage is January 1, 2019.
    • Applications made after December 15, 2018 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 12/31/2018 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

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