Frequently Asked Questions

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Claims and Payment Policy

Will I be responsible for any out of pocket costs billed by a Non-Participating (Out of Network) Provider?

In general, a member must receive covered services from a participating provider; otherwise, the services are not covered, the member will be 100% responsible for payment to the non-participating provider, and the payments will not apply to the member’s deductible or annual out-of-pocket maximum. However, a member may receive covered services from a non-participating provider for emergency services or subject to prior authorization in accordance with the following sections of the Agreement:

  • “Non-Participating Provider at a Participating Provider Facility
  • “No Participating Provider to Provide a Covered Service”
  • “Continuation of Care (Continuity of Care)”
  • “Transition of Care”

Because non-participating providers are not in Molina's contracted provider network, they may balance bill members for the difference between Molina's allowed amount and the rate that they charge.  Members may avoid balance billing by receiving all covered services from participating providers.

How are claims for covered medical services submitted for payment under my plan?

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 20 days from the date you made the payment or as soon as reasonably possible.

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 South Carolina, Inc.
Member Services
PO Box 40309
North Charleston, SC 29423
1 (855) 885-3176

What is my grace period?

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 will provide a Grace Period of 31 consecutive days for a Subscriber and their Dependents, who when failing to timely pay Premiums, are not receiving an APTC. The Grace Period will begin the first day of the first month for which full Premium is not received by Molina. During the Grace Period, Molina will pay all appropriate claims for services rendered to the Subscriber and their Dependents. Molina will terminate this Agreement as of 11:59 p.m. Eastern on the last day of the Grace Period if Molina does not receive all past due Premiums from the Subscriber. You will still be responsible for any unpaid premiums you owe Molina for the grace period.
  • Grace Period for Subscribers with APTCs: Molina will provide a Grace Period of 3 consecutive months for a Subscriber and their Dependents, who when failing to timely pay Premiums, is receiving an APTC. The Grace Period will begin the first day of the first month for which full Premium is not received by Molina. During the Grace Period, Molina will pay all appropriate claims for services rendered to the Subscriber and their Dependents during the first month of the Grace Period and may pend claims for services in the second and third months of the Grace Period. 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, Molina will terminate this Agreement as of 11:59 p.m. Eastern on 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.

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 of premium to Molina?

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.

What is Medical Necessity?

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.

What is a Prior Authorization, and how does it impact services under my plan?

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.

Routine prior authorization requests will be processed within 5 business days of receiving complete information from your doctor.

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.

Prior Authorization requirements for Covered Services are subject to change, and you should contact Member Services or visit www.MolinaMarketplace.com/SCGetCare prior to receiving services to determine what services require prior authorization. If you do not obtain prior authorization for the specified services, claims for benefit payment may be denied, impacting your out of pocket costs.

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, 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 "Universal Prior Authorizations Medications Form" and directions for completing the request can be found here.

Molina Marketplace
Member Services: (855) 885-3176
Provider Services: (855) 237-6178
Fax: (855) 571-3011

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.

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.

What is an Explanation of Benefits (EOB)?

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.

What is Coordination of Benefits (COB)?

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.

Enrollment

How can I enroll for coverage?

Visit www.MolinaMarketplace.com to see if you qualify for financial assistance and enroll into a Molina plan. You can also speak to one of our Certified Enrollers who can help you apply over the phone by calling (844) 713-1481, or you can find a certified enrollment partner in your area who can assist you in person.

When is Open Enrollment?

Open enrollment for 2022 is November 1, 2021 through January 15, 2022.

Complete your enrollment application by December 15, 2021 for a January 1, 2022 effective date.

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 is a Special Enrollment Period?

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, 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 or household size
  • You lose your health coverage, including no longer being eligible for Medicaid, losing your coverage through your job, or exhausting your COBRA coverage
  • Have a change in disability status
  • 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.
  • Leaving incarceration

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.

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.

As a new member, when will my coverage start?

  • If you apply between November 1, 2021, and December 15, 2021, the effective date of your coverage is January 1, 2022.
  • If you apply between December 16, 2021, and January 15, 2022, the effective date of your coverage is February 1, 2022.
  • 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 my insurance coverage with Molina?

Log into your MyMolina.com online member account and visit the Eligibility & Benefits tab. Your account allows you to review your Evidence of Coverage, Summary of Benefits, Schedule of Benefits, and other plan materials that are customized to your plan.

How do I discontinue my coverage?

Please contact Member Services using the telephone number on the back of your ID card, for further steps on discontinuing your coverage.

Who do I call If I have questions on my current benefits?

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

How do I make a payment?

To make a payment for your monthly premium, go to MyMolina.com and click on the $ icon. We provide several payment options for your convenience. We accept Visa, MasterCard and Discover Card or electronic check. You can also sign up for automatic payments through AutoPay. It is convenient and worry free!

For additional ways visit our Make a Payment page.

How long after enrolling will members receive an invoice?

  • If you are a new member, you will receive a paper invoice within 7-10 business days after enrollment.

  • If you are a renewing member, you will receive an invoice by the 15th of every month.

How will my premiums be impacted if I am eligible for APTC?

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 Healthcare.gov and update your information.

I have a question or concern about a payment or invoice. What should I do?

If your payment is not reflected on your recent invoice, it may have been received after the invoice was generated. Check the date on your invoice compared to the date your payment cleared your bank account. If you don’t have your paper invoice, you can find it on MyMolina.com. Feel free to contact us if you need additional assistance.

I have an issue with my auto-payment. What should I do?

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.

Can I set up an auto-payment?

Yes, it is easy to do so by setting up your My Molina online member 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 My Molina online member account.

When are payments due?

Payments are due on the last calendar day of the month.

How long does it take to process payments?

3-5 business days depending on how long it takes your bank to process the transaction.

When will my auto-payment be taken from my account?

Auto payments will be processed on the last day of the month or the next business day if the last day falls on a weekend or holiday, 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. 

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 online member account to find out your balance, or call the customer support number located here.

Provider and Pharmacy Network

How do I find a participating provider in my area?

To determine which participating provider is in your area go to the Provider Online Directory and follow the steps below.
  1. Select Molina Marketplace under Plan/Program located at the top of the page.
  2. You have the option to enter “City”, “County”, “State” or “Zip Code”.
  3. Search options include “Browse by Category” and “Search Bar” where you can enter a name or a specialty to search for a doctor or facility.

How do I find a participating provider that is accepting new patients?

To determine which participating provider is accepting new patients go to the Provider Online Directory and follow the steps below.
  1. Select Molina Marketplace under Plan/Program located at the top of the page
  2. You have the option to enter “City”, “County”, “State” or “Zip Code”.
  3. Search options include “Browse by Category”, “Search Bar” where you can enter a name or a specialty to search for a doctor or facility.
  4. Select View Only “Accepting New Patients”

How do I know which providers I can go to?

To view the providers available in your network, visit the Provider Online Directory.

How do I select or change a Primary Care Provider (PCP)?

You can select a Primary Care Provider (PCP) once your coverage is effective with the plan. To select a PCP, visit MyMolina.com to view our online provider directory and select a PCP in your area. Additionally, if you’re an existing member and would like to change your PCP, you can visit MyMolina.com anytime to make a change.

What happens if my PCP leaves the network?

If your doctor leaves the network, you will need to select another Molina participating provider, refer to our provider online directory to view doctors and hospitals.

Under limited circumstances, you may be able to continue with your PCP for continuation of coverage as described in the Agreement.

Please contact us for more information.

How do I know what pharmacies to go to?

Your pharmacy network is through CVS. You can see which pharmacies are available to you. Go to 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). This information is also available in your My Molina online member account.

Member Services

Can someone else contact Molina on my behalf?

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.

How do I reset my MyMolina online member account password?

Visit mymolina.com and click on “Forgot User ID or Password?” and follow all the steps to complete the password reset.

How do I update my address or contact information?

Updates to your address or contact information may impact your coverage. You will need to contact the Exchange to update your contact information.

I enrolled in a Molina plan. When can I register on the "My Molina" online member portal to see my benefits and services?

You can register on the My Molina online member portal once your initial payment is processed and you become effective with the plan.

How can I get a new or replacement ID card?

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

What is a My Molina online member account and what can I do with it?

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 ton 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!

How do I set up My Molina online member account?

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.

How can I access My Molina online member account on my smart phone?

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.

Does Molina offer Telehealth or Telemedicine Services?

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.

Were you Automatically Enrolled to Molina?

Who automatically enrolled me with Molina, I did not sign up with Molina?

As of 12/31/2021 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.

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.

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