|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 member see's a non-participating provider!|
Molina does not restrict You from freely contracting at any time to obtain any health care services outside the
health care Policy on any terms or conditions You choose. However, You will be 100% responsible for payment
and the payments will not apply to Your Deductible or Annual Out-of-Pocket Maximum for any of these services.
For exceptions please review 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 Policy. However, You are responsible for paying charges for any health care services or treatment, which are not Covered Services under this Policy.
|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?
||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 "Grievances" section, below. If You are still not satisfied, You may call the Washington State Office of the Insurance Commissioner for instructions on filing a consumer complaint. Call 1 (800) 562-6900 or 1 (360) 725-7080, or visit Washington State Office of the Insurance Commissioner website at www.insurance.wa.gov.
|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.
|What is Prior Authorization, and how does it impact services under my plan?
A Prior Authorization is an approval from Molina which 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 .Molina’s Medical Directors work in collaboration with participating providers to assure clinically appropriate or clinically significant care is delivered to our members, in terms of the type, frequency, event, or service site of care, according to generally accepted applicable practice guidelines. They decide on the Medical Necessity before the care or service is given. This is to ensure you receive the right care for Your specific condition. Within thirty days of receiving a request, Molina will furnish its medical necessity criteria for medical/surgical benefits and mental health/substance use disorder benefits or for other essential health benefit categories to an enrollee or provider when requested.|
If additional information is needed to make the Prior Authorization determination, Molina will approve or deny the request within four calendar days of the receipt of the additional information. Urgent Prior Authorization requests related to medical conditions that may cause a serious threat to Your health are processed within 48 hours. This is 48 hours from when We get the information We need and ask for to make the decision. In the event that the urgent Prior Authorization request is also a concurrent review request, Molina will make a determination as soon as possible and no later than 24 hours after receipt, provided that the Prior Authorization request is made at least 24 hours prior to the expiration of the previously approved period of time or number of treatments. For post-service review requests, Molina will make its determination within thirty calendar days. We will deny a Prior Authorization if information We request is not provided to Us within the required timeframe.
|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?
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 1 (888)858-3492. We are here Monday through Friday, 7:30 a.m. through 6:30 p.m. PT. 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.
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 Policy 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 through this exception process, 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:
- Document in Your medical record;
- Certify that the Drug Formulary alternative has not been effective in Your treatment; or
- 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 Policy:
- 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 a request for services is denied, the requesting provider and the member will receive a letter explaining the reason for the denial and additional information regarding the grievance and appeals process. Denials also are communicated to the provider by telephone, fax or electronic notification. Verbal, fax, or electronic denials are given within one business day of making the denial decision or sooner if required by the member’s condition.
If initial request is denied through this exception process, 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 IRO review of the Expedited Exception Request
- 72 hours following receipt of request for IRO review of the Standard Exception Request
Molina will cover off-label use of a drug to treat You for a covered chronic, disabling, or life-threatening illness if the drug (1) has been approved by the FDA for at least one indication, and (2) is recognized as an effective drug for treatment of the indication in any standard drug reference compendium or any substantially accepted peer-reviewed medical literature. Off-label drug use must be Medically Necessary to treat Your covered condition, and must be Prior Authorized. We will not deny coverage of off-label drug use solely on the basis that the drug is not on the Drug Formulary.
|What is an Explanation of Benefits (EOB)?
You will receive an explanation of benefits so that You will know what has been paid. All benefits paid under this Policy on behalf of a covered Dependent child for which benefits for financial and medical assistance are being provided by the Washington Health and Human Services Commission shall be paid to said department when the parent who purchased the individual has possession or access to the child pursuant to a court order, or is not entitled to access or possession of the child and is required by the court to pay child support. Molina Healthcare must receive at its Washington office, written notice affixed to the claim when the claim is first submitted, and the notice must state that all benefits.
|What is Coordination of Benefits (COB)?
COORDINATION OF BENEFITS (pg 74-79)|
This 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 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.