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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!

    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:

    • for Emergency Services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services”,
    • for out-of-area Urgent Care Services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,” and
    • for exceptions described in the section of this 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? In most cases, Participating Providers will ask You to make a payment toward Your Cost Sharing at the time You check in. This payment may cover only portions of the total Cost Sharing for the Covered Services You receive. The Participating Provider will bill You for any additional Cost Sharing amounts that are due.

    The Participating Provider is not allowed to bill You for Covered Services You receive other than for Cost Sharing amounts that are due under this Agreement. However, You are responsible for paying charges for any health care services or treatment which are:
    • not Covered Services under this Agreement,or
    • provided by a Non-Participating Provider, except that Molina will cover services from a Non-Participating Provider:
    • for Emergency Services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,”
    • for out-of-area Urgent Care Services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services,” and
    • for exceptions described in the section of this Agreement titled “What if There Is No Participating Provider to Provide a Covered Service?”
    What is my grace period?
    • 15-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 15-day 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? If the amount of the payments made by Molina is more than we should have paid under this COB provision, we may recover the excess from one or more of the persons we paid or for whom we had paid, or any other person or organization that may be responsible for the benefits or services provided for the Member. The “amount of the payments made” includes the reasonable cash value of any benefits provided in the form of services.

    If You believe that we have not paid a claim properly, You should first attempt to resolve the problem by contacting us. Follow the steps described in the "Complaints" section, below. If You are still not satisfied, You may call the Utah Insurance Department, Health Insurance Division, Consumer Services for instructions on filing a consumer complaint. Call 1 (801) 538-3077, or visit Utah Insurance Department, Health Insurance Division, Consumer Services website at www.insurance.utah.gov.
    What is Medical Necessity? “Medically Necessary“ or “Medical Necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms. Those services must be deemed by Molina to be:

    1) In accordance with generally accepted standards of medical practice;
    2) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
    3)Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.
    4)For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, the views of physicians practicing in relevant clinical areas and any other relevant factors.
    What is Prior Authorization, and how does it impact services under my plan? Your plan requires that you obtain a medical necessity review of certain services, prior to obtaining those services to be covered under your plan. Prior authorization is a process for Molina and your doctor, to review the medical necessity of your care before the care or service is given. This is to ensure that the proposed services are appropriate for your specific condition and that appropriate utilization review can occur.

    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.

    Routine prior authorization requests will be processed within 5 business days of receiving complete information from your doctor, and Molina will respond to prior authorization requests within 14 calendar days.

    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.
    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 community. The group meets every three months to talk about the drugs that are in the formulary. They review new drugs and changes in health care. They try to find the most effective drugs for different conditions. Drugs are added or removed from the Drug Formulary for different reasons. This could be:

    • Changes in medical practice
    • Medical technology
    • When new drugs come on the market.

    You can look at Our Drug Formulary on Our Molina Healthcare website. The address is MolinaMarketplace.com. You may call Molina Healthcare and ask about a drug. Call toll-free at 1 (888) 858-3973. TTY users may dial 711. 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 us with the Telecommunication Service.

    You can also ask Us to mail You a copy of the Drug Formulary. A drug listed on the Drug Formulary does not guarantee that Your doctor will prescribe it for You.
    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)? This Coordination of Benefits (“COB”) provision applies when a person has health care coverage under more than one Plan.

    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 accordance with its policy 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 do not exceed 100% 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 2019 has ended. Individuals may qualify for enrollment outside of Open Enrollment through a Special Enrollment Period.

    Open enrollment for 2020 is November 1, 2019 through December 15, 2019.
    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:
    • 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
    • You lose your health coverage, including no longer being eligible for Medicaid or losing your coverage through your job
    • Get Health coverage through a job or a program like Medicare or Medicaid
    • Change your place of residence
    • Have a change in disability status
    • Become pregnant
    • 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.
    • 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, 2019, the Effective Date of Your coverage is January 1, 2020.
    • Applications made after December 15, 2019 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 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 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 12/31/2019 your current health plan will no longer offer your 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 if you are a registered userto 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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