Molina Healthcare of New Mexico may not restrict you or your eligible dependents who are enrolled in this policy from seeking medical treatment with a non-participating provider. However, should you or your eligible dependents who are enrolled in this policy obtain medical treatment with a non-participating provider 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 following sections of the Agreement titled “Emergency Services and Urgent Care Services”, and “What if There Is No Participating Provider to Provide a Covered Service?.”
• Emergency Services
• Post Stabilization Services, unless the Member waives Balance Billing protections
• Services by a Non-Participating Provider at a Participating Facility that is a hospital, ambulatory surgical center or other Participating Facility required by State Law, unless the Member waives Balance Billing protections and Post Stabilization Services
• Services from a Non-Participating Provider that are subject to Prior Authorization (including providers for mental health or substance use disorder services)
• Exceptions described in the “Non-Participating Provider at a Participating
Provider Facility” section
• Exceptions described in the “No Participating Provider to Provide a Covered
Service” section
• Exceptions described in the “Continuity of Care” section
• Exceptions described in the “Transition of Care” section
• In the event medically necessary covered services are not reasonably available through a participating provider, Molina and the PCP or other participating provider shall refer a covered person, once prior Authorization is obtained, to a nonparticipating health care professional and shall fully reimburse the non-participating health care professional at the usual, customary, and reasonable rate or at an agreed upon rate. Before Molina denies a referral to a non-participating provider or health care professional, the request will be reviewed by a specialist similar to the type of specialist to whom a referral is requested.
To locate a Participating Provider, please refer to the provider directory at
MolinaMarketplace.com or call Member Services to request a hard copy. Molina will
provide an updated provider list biennially, pursuant to 13.10.23.8D NMAC.
Notice of Claim
Written notice of a member’s claim relating to covered services under this EOC, when applicable (a “claim”) must be given to Molina Healthcare within 20 days after the claim for reimbursement or payment of covered services under this EOC becomes owing, or as soon thereafter as is reasonably possible. Notice of the claim given by or on behalf of the member to Molina Healthcare at the following address, with information sufficient to identify the member and the nature of the claim, shall be deemed notice to Molina Healthcare:
Molina Healthcare P.O. Box 22801 Long Beach, CA 90802
Upon your submission of a claim to Molina Healthcare, Molina will calculate the amount of the claim that may be due to you in accordance with this agreement and applicable state and federal laws. If amounts subject to the claim are owing to you, such amounts may be reduced by applicable cost sharing.
Claim Forms
Molina Healthcare, upon receipt of a notice of claim from a member as provided above, will furnish to the member such forms as are usually furnished by Molina Healthcare for filing proofs of loss (if such additional forms are appropriate and required by Molina) with respect to such claims. If Molina Healthcare does not furnish such required forms to the member within 15 days after the notice of claim has been given to Molina, the member shall be deemed to have complied with the requirements of this EOC as to proof of loss upon submitting, within the time fixed by this EOC for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is being made.
Proof of Loss
If required or appropriate as determined by Molina Healthcare, written proof of loss relating to a claim must be furnished to Molina at its office (identified in the “Notice of Claim” section above) within 365 days after the occurrence or start of the loss on which the claim is based to validate and preserve the claim. If written proof of loss is not given within that time, the claim will not be invalidated, denied or reduced if it is shown that written proof of loss relating to a claim was given as soon as was reasonably possible or legal incapacity of the member extended the time period for providing such proof of loss. Foreign claims and proof of loss relating to such claims must be translated in U.S. currency prior to being submitted to Molina Healthcare.
Time of Payment of Claims
Upon the timely receipt of the proof of loss (if required by Molina Healthcare) and all other information necessary to evaluate, process and pay a claim under this EOC, Molina Healthcare will pay the claim within 60 days after receipt of such proof of loss and other information. Payment of claims by Molina requires that documentation, however submitted to Molina, be in form and content reasonably acceptable to Molina and contain all required information for processing without the need for additional information from outside of Molina Healthcare. Interest penalties will not be applied to claims not paid within the timeframes stated.
A grace period is a period of time after a member’s premium payment is due and has not been paid in full. If a subscriber hasn’t made full payment, they may do so during the grace period and avoid losing their coverage. The length of time for the grace period is determined by whether or not the subscriber receives an advance payment of the premium tax credit (APTC).
- Grace Period for Subscribers with No APTC: 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 at the end of the grace period. You will still be responsible for any unpaid premiums you owe Molina for the grace period.
- Grace Period for Subscribers with APTCs: 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. During months two and three your coverage will be suspended and Molina will pend all appropriate claims for services rendered to the subscriber and their dependents pursuant to the terms of this agreement. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. 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.
Retroactive denial of claims does not apply to services that Molina has pre-authorized.
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 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 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 a prior approval.
You should consult your agreement 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.
For Non-Urgent or Routine Medicine authorization requests– if you do not have an urgent need for a prescription drug, Molina will resolve the request within three business days if your provider:
o Uses the prior authorization request form approved by the New Mexico
Office of Superintendent of Insurance;
o Requests an exception from an established step therapy process; or
o Requests to prescribe a drug that Molina does not usually cover.
For all other routine prior authorization requests, Molina will provide a decision within seven (7) business days of receipt of the request.
Medical conditions that may cause a serious threat to your health are processed within 24 hours from receipt of all information, or shorter as required by law. These are considered urgent requests.
Meeting these time frames depends on our receipt of sufficient information to evaluate the request. If we do not deny a complete prior authorization request within these time frames the request is automatically approved.
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 "New Mexico Prior Authorization Form" and instructions for completing the request can be found here.
Molina Marketplace
Provider Phone: (855) 322-4078
Member Phone: (888)-295-7651
Fax: (866) 472-4578
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.
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.
For more information about Open Enrollment and Special Enrollment Periods, please visit beWellnm.com or call them at the beWellnm Customer Engagement Center at 1-833-862-3935 during the following hours (please note the following are Mountain time below):
beWellnm Operating Hours
- 8:00 AM – 5:00 PM Monday through Friday.
Open enrollment for 2025 is November 1, 2024 through January 15, 2025.
Complete your enrollment application by December 31, 2024, for a January 1, 2025, effective date.
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.
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 or divorced
- Having a baby or adopting a child
- Moving to a new area
- Loss of coverage under your parent’s plan
- Loss of job-based coverage
- Loss of other types of coverage
- Have a change in income or household size
- Gaining citizenship or lawful presence in the United States
- 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.
Other qualifying life events may apply. For more information, visit beWellnm.com.
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
beWellnm.com and update your information.
Without health insurance, you may suffer catastrophic financial losses due to illness or injury.
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.
- If you apply on or before December 31, 2024, the effective date of your coverage is January 1, 2025.
- If you apply between January 1, 2025, and January 15, 2025, the effective date of your coverage is February 1, 2025.
- 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.
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.
To make a payment for you monthly premium, got to beWellnm.com or call at 1-833-862-3935 local time (Mountain time). They provide several payment options for you convenience. They accept Personal/Cashier's Checks, Money Orders, Automated Clearing House (ACH), and Debit/Credit Cards. You can also sign up for recurring payments. It is convenient and worry free!
For the initial payment, the subscriber/policyholder does not have to wait for an invoice. The subscriber/policyholder can pay online at the point of enrollment from their beWellnm.com account. When paying online, the subscriber is limited to ACH and credit/debit cards.
Consumers, who are currently enrolled on the Exchange with financial assistance and experience a change that impacts their APTC and/or CSR will have their updated APTC amount applied to their enrollment, as follows:
- If changes are made by the 23rd of the month, new APTC amount will be effective at the 1st of the following month of the change.
- If changes are made on 24th of the month or after, the new APTC amount will be effective at the 1st of the second month following the change – e.g., for a change made on April 24, new APTC would be applied on June 1. Individuals are required to report any changes that may affect their eligibility for coverage, APTC, and CSRs within 30 days of the change.
Consumers who are currently enrolled on the Exchange with no financial assistance and subsequently gain eligibility for APTC will have the new APTC amount applied to their premiums as described above. Please go to beWellnm.com and update your information.
Please visit beWellnm.com or call them at the beWellnm Customer Engagement Center at 1-833-862-3935 during the following hours (please note the following are Mountain time below):
beWellnm Operating Hours
- 8:00 AM – 5:00 PM Monday through Friday.
Please visit
beWellnm.com or call them at the beWellnm Customer Engagement Center at 1-833-862-3935 during the following hours (please note the following are Mountain time below):
beWellnm Operating Hours
- 8:00 AM – 5:00 PM Monday through Friday.
Yes, it is easy to do so through beWellnm.com and following the prompts to make a payment, which will lead you to the recurring payments option.
Automated Clearing House (ACH).
Payments are due on the 23rd of the month for coverage to begin the 1st of the following month.
3-5 business days depending on how long it takes your bank to process the transaction.
Recurring payments will be processed on the 18th of every month prior to the due date of the 23rd, 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 Recurring payments, whichever comes first.
We accept only one recurring payment per month, which will be deducted from your account in full.
Please visit bewellnm.com or call them at the beWellnm Customer Engagement Center at 1-833-862-3935 during the following hours (please note the following are Mountain time below):
beWellnm Operating Hours
- 8:00 AM – 5:00 PM, Monday through Friday.
Molina needs to have a power of attorney or PHI form in your file indicating the caller is authorized, if the caller is not authorized the member can provide a verbal consent. The verbal consent will grant the caller permission to speak on their behalf, but it is only good for 14 business days. At the member’s request, Molina can send a PHI form to the address on file to avoid future verbal consents.
Visit
mymolina.com and click on “Forgot User ID or Password?” and follow all the steps to complete the password reset.
Updates to your address or contact information may impact your coverage. You will need to contact
beWellnm.com to update your contact information.
You can register on the
My Molina online member portal once your initial payment is processed and you become effective with the plan.
Once we receive your initial payment, you will receive your new ID card in the mail within 5-7 business days.
If you need a replacement or additional ID card, you can view and print one within your secure
My Molina online member account.
Go to
MyMolina.com and register your personal online member account today!
If you are having trouble,
contact us and we can help
Your
My Molina online member account is a powerful tool that puts you in control of your health coverage. It’s easy to set up and lets you manage your account wherever you are on a computer or your smart phone.
Use your
My Molina online member account anytime to conveniently do things like:
- Access your digital ID card and download view it to your smart phone, or print it or request a new ID card to be sent to your current address on file with Molina
- Choose or change your Primary Care Physician (PCP)
- View Billing Information
- Make a Payment
- Sign up for automatic monthly payment through AutoPay
- Check to see if we cover your prescription drugs
- Quick links to benefit coverage and much more!
Go to
MyMolina.com and register your personal online member account today!
Setting up your
My Molina online member account is easier than ever- it only takes a few minutes.
Go to
MyMolina.com and complete a few simple steps to register. Be sure to have your Member ID number, Date of Birth, and State where you are enrolled.
MyMolina.com can be accessed by your desktop or mobile device.
You can download “My Molina Mobile” from your app store using your smart phone.
My Molina Mobile is a self-service mobile application for Molina members. My Molina Mobile has many features and will allow you to have the same access as your
My Molina online member account.
Yes. For more information or to create an account, visit the
Virtual Care page.
To view your specific benefit coverage, visit your
My Molina online member account.
As of 12/31/2024 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 31, for a January 1 start date.
Please go to beWellnm.com to review your plan options.
Please go to beWellnm.com and update your information.
Yes, you and your dependents will be automatically enrolled in Molina, if they were
covered by your previous insurer.
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
Find helpful resources, plan materials, payment information and more.
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