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Members

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:

    1) for Emergency Services in accordance with the section of the Agreement titled “Emergency Services and Urgent Care Services”, and
    2) 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 a portion 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 EOC.
    Please note: You are responsible for paying charges for any health care services or treatments that are not Covered Services under this EOC. This may include charges for any health care services provided by Non-Participating Providers (such as, but not limited to, emergency room providers, radiologists, anesthesiologists, or pathologists). This may include any Non-Participating Provider who is delivering services in a Participating Provider hospital.
    What is my grace period?
    • 10-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 10-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? 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 that a physician, exercising prudent clinical judgment, would provide to a patient. This is 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:
    • In accordance with generally accepted standards of medical practice;
    • Clinically appropriate and clinically significant, in terms of type, frequency, extent, site and duration. They are considered effective for the patient’s illness, injury or disease; and
    • Not primarily for the convenience of the patient, physician, or other health care provider. The services must not be more costly than an alternative service or sequence of services. They are 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.
      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? A Prior Authorization is a request for You to receive a Covered Service from Your doctor. Molina’s Medical Director and Your doctor work together. They decide on the Medical Necessity before the care or service is given. This is to ensure it is the right care for Your specific condition.
    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 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 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 or removed from the Drug Formulary based on changes in medical practice and medical technology. Drugs can also be added to the Drug Formulary when new drugs come on the market. Molina has a process in place to allow You, or someone You designate to act on Your behalf, and Your prescribing physician to request and gain access to clinically appropriate drugs that are not covered under Your product. If Your doctor orders a drug that is not listed in the Drug Formulary that he or she believes is best for You, then You, or someone You designate to act on Your behalf, and Your prescribing physician may contact Molina’s Pharmacy Department to Prior Authorization for Molina to cover the drug for You. If the request is approved, Molina will contact You, or someone You designate to act on Your behalf, and Your prescribing physician. If the request is denied, Molina will send a letter stating why the drug was denied. If you are approved for a non-Drug Formulary brand name drug in lieu of a Formulary Generic drug, you will be responsible for payment as described in the section of this Agreement titled “Tier-1 Formulary Generic Drugs.” If You are 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 Your disease or condition; or
    • When the Drug Formulary alternative causes or is reasonably expected by Your doctor to cause a harmful or adverse reaction in You. 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, or someone You designate to act on Your behalf, and Your prescribing physician 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 the initial request is denied, You, someone You designate to act on Your behalf, or Your prescribing physician may request an external review. You, or someone You designate to act on Your behalf, and Your prescribing physician will be notified of the external review decision no later than:
    • 24 hours following receipt of the request for external review of the Expedited Exception Request
    • 72 hours following
    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. For purposes of this COB provision, “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.
    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
    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 or 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

    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.
  •  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 usto 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 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 plan in our 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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