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,”
2. for out-of-area urgent care services in accordance with the section of the agreement titled “Emergency Services and Urgent Care Services,”
3. for exceptions described in the section of the agreement titled “What if There Is No Participating Provider to Provide a Covered Service?,” and
4. for exceptions described in the section of the agreement titled “Non-Participating Provider at a Participating Provider Facility.”
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 California
200 Oceangate, Suite 100
Long Beach, CA 90802
1 (888) 858-2150
- If you do not receive advance payment of the premium tax credit, Molina Healthcare will give you a thirty (30) calendar-day grace period before cancelling or not 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 (30) 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 at the end 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.
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.
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.
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.
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.
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.
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. 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 request for expedited exception request
- 72 hours following receipt of request for 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.
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.
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.
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 CoveredCa.com
and update your information.
Please visit your Auto Pay account in your My Molina online member account located here
If you are having trouble, contact us
and we can help.
Yes, it is easy to do so by setting up your MyMolina
online member account and following the prompts to make a payment, which will lead you to the Auto Pay options.
Electronic Funds Transfer (EFT), checking account, or credit card, by visiting your MyMolina
online member account.
Auto-payments will be deducted on the 23rd of the month, or the next banking day if the 23rd is a holiday or weekend, for the total balance due of your health insurance premiums.
This remains in effect for as long as you are covered with Molina, or until you cancel AutoPay, whichever comes first.
We accept only one auto-payment per month, which will be deducted from your account in full.
Please register and/or sign into your MyMolina
online member account to find out your balance, or call the customer support number
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.
Yes. You may select a different health plan until December 15, for a January 1 start date.
Please go to Covered California to review your plan options.
Please go to Covered California and update your information.
Yes, you and your dependents will be automatically enrolled in Molina, if they were
covered by your previous insurer.
Whenever you make a permanent move, you must update your address on Healthcare.gov
, Covered California
If you are eligible for tax credits and your family size and/or income has not changed,
you will continue to receive tax credits.
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.
Yes, but you need to continue to pay your current/previous insurer until the end of the year.
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.
After you make your initial payment, you will receive your ID card within 10 days.
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.
For your convenience, we have a Provider Online Directory where you can search for available choices in your area. Go to Provider Online Directory
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
To view all of our covered formularies, go to Molina Healthcare Drug Formulary
You can contact member services to answer any questions you may have
COVID–19 is a new strain of virus (coronavirus), which began in Wuhan City, China. The name COVID-19, is short for “coronavirus disease 2019.” This virus causes a lung illness, and has infected thousands of people worldwide. Organizations (CDC and WHO) are actively monitoring the outbreak of this new coronavirus strain. (Visit the CDC’s Traveler’s Health website for travel notices and advisories).
Common signs of infection include fever, cough, and lung symptoms such as shortness of breath and breathing difficulties. In more severe cases, this virus can cause infection in the lungs (pneumonia), severe lung problems (acute respiratory distress syndrome), kidney failure, and even death. People with heart and lung disease or weakened immune systems, as well as infants and older adults, are at higher risk for more severe problems from this illness.
It is thought to be spread by little fluid droplets from an infected person’s lungs to others through:
- the air by coughing and sneezing.
- close personal contact such as touching or shaking hands.
Although there are no vaccines available to protect against this virus, you may be able to reduce your risk of infection by:
- washing your hands often.
- avoiding touching your eyes, nose, or mouth with unwashed hands.
- avoiding close contact with people who are sick.
If you have cold-like symptoms, contact your employer to see if they want you to remain at home while you are sick.
If you share a work station or equipment with others, consider wiping it down with disinfectant wipes after use.
Most people with this illness will recover on their own. Although there are no treatments for illnesses caused by this type of virus (human coronavirus), you can take the following actions to help relieve symptoms if you are mildly sick:
- Take pain and fever medications. Ask your pharmacist how they may interact with any medications you currently take. (NOTE: The CDC and American Academy of Pediatrics (AAP)
recommend not giving aspirin to children).
- Drink plenty of liquids.
- Stay home and rest.
- Use the Molina Nurse Advise Line to discuss your symptoms and treatment options.
- Consider a telemedicine visit if you are not very ill, (as long as it is a covered benefit on your plan).
- If you are concerned about your symptoms, please contact your local health care provider.
No, but since there is no treatment for COVID-19, getting available immunizations for other lung infections (such as flu, pneumonia and whooping cough) may be a good idea. This is important for those who have weakened immune systems or who may have a more serious illness.
The Centers for Disease Control (CDC) recommends that anyone with symptoms of COVID-19, anyone who is returning from a high
risk place (Centers for Disease Control designated “Level 2” or “Level 3” advisory area), or anyone who has been in contact with someone who has or may have the virus within the last 14 days, should be tested. Your provider can help decide if you should be tested.
Patients who have concerns that they may have had contact with COVID-19 or may have symptoms of COVID-19 or have returned from a high risk place (Centers for Disease Control designated “Level 2” or “Level 3” advisory area should contact their primary care provider to discuss whether to get tested. If you meet the rules for testing (per the CDC) then your doctor can order the test. The test will likely be nasal swabs that are then sent to a laboratory.
Yes. As long as you meet the guidelines for testing and have a doctor’s order, this testing can be done in any approved laboratory location. At this time, you will not be charged a co-pay or cost share for this testing based on CDC guidance recommendation or a medical provider orders the testing.
Where it is a covered benefit, Molina members should consider telemedicine as an option. Such “virtual visits” may lessen the risk of exposure to other sick people in doctors’ offices.