Frequently Asked Questions
- 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 services 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.
- Emergency services obtained for treatment of an emergency medical condition within or outside of the service area of your plan, are considered a covered service 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? 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 Texas, Inc.
5605 MacArthur Blvd, Suite 400
Irving, TX 75038
1 (888) 560-2025
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 on the last day of the month prior to the beginning 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 3 calendar days of receiving complete information from your doctor, and will process expedited authorizations within 24 hours.
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 "Texas Standardized Prior Authorization Request Form for Prescription Drug Benefits" and directions for completing the request can be found here.
Phone: (855) 322-4080
Fax: (888) 487-9251
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.
When is Open Enrollment? Open enrollment for 2020 has ended. Individuals may qualify for enrollment outside of Open Enrollment through a Special Enrollment Period.
Open enrollment for 2021 is November 1, 2020 through December 15, 2020.
What is a Special Enrollment Period Conditions that may 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:
- Getting Married, divorced or legally separated
- Have a child, adopt a child, or place a child for adoption
- Death of someone on your plan
- Change your place of residence
- Have a change in income or household size
- You lose your health coverage, including no longer being eligible for Medicaid, losing your coverage through your job, or exhausting your COBRA coverage
- Have a change in disability status
- You return from active-duty military service
- You become a citizen, national or lawfully present individual
- If you are a member of a federally recognized American Indian or Alaska Native tribe, you can enroll anytime and change plans no more than once per month.
- Leaving incarceration
Other qualifying life events may apply. For more information, visit healthcare.gov.
What if my income changes or my family size changes? Do I need to do anything?
- If your income or household size has changes, you will need to report that to 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.
How will my premiums be impacted? 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 MyMolina portal located here. Can I set up an auto-payment? Yes, it is easy to do so by setting up your MyMolina 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 MyMolina 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 MyMolina account to find out your balance, or call the customer support number located here.
- Provider and Pharmacy Network
How do I know which doctors I can go to? You can choose a Primary Care Provider. To determine who might be best for you, go to the Provider Online Directory. 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 Pharmacy locator.
- 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 12/31/2020 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
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