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 (in-network) providers, in order for those services to be a covered service under your plan. Services provided by non-participating (out of network) providers without being prior authorized by Molina, are not covered services, and you will be 100% responsible for payment to non-participating providers, and the payments will not apply to any applicable deductible or annual out-of-pocket maximum under your plan. However, a Member may receive Covered Services from a Non-Participating Provider for the following:
• Emergency Services and Post Stabilization Services
• Services from a Non-Participating Provider that are subject to Prior Authorization
• Exceptions described in the “Non-Participating Provider at a Participating Provider Facility” section
• Exceptions described in the “If There Is 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
To locate a Participating Provider, please refer to the Provider directory at
MolinaMarketplace.com or call Member Services. 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.
Members may refer to MolinaMarketplace.com or contact Member Services for
additional information regarding protections from Balance Billing through Federal and State Law.
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.
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 (30) calendar-day grace period before cancelling or non renewing your coverage due to failure to pay your premium. Molina will pend all appropriate claims for services rendered to the subscriber and their dependents pursuant to the terms of this agreement. 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 on the last day of the month prior to the beginning 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. 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.
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 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.
For electronic routine or standard prior authorization requests, Molina will provide decisions within three (3) calendar days, excluding holidays, after obtaining the necessary information to make the determination. If insufficient information has been provided to make a decision, Molina will request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization.
For nonelectronic routine or standard prior authorization requests, Molina will provide decisions within five (5) calendar days, after obtaining the necessary information to make the determination. If insufficient information has been provided to make a decision, Molina will request any additional information from the provider or facility within five calendar days of submission of the electronic prior authorization.
For electronic expedited/urgent prior authorization requests, Molina will provide decisions within one (1) calendar day, after obtaining the necessary information to make the determination. If insufficient information has been provided to make a decision, Molina will request any additional information from the provider or facility within one calendar days of submission of the electronic prior authorization.
For nonelectronic expedited/urgent prior authorization requests, Molina will provide decisions within two (2) calendar days, after obtaining the necessary information to make the determination. If insufficient information has been provided to make a decision, Molina will request any additional information from the provider or facility within one calendar days of submission of the electronic prior authorization.
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 "Drug Prior Authorization Form" and instructions for completing the request can be found here.
Molina Marketplace
Member Phone: (888) 858-3492
Provider Phone: (855) 322-4082
Fax: (800) 869-7791
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.
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.
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.
Open enrollment for 2025 is November 1, 2024, through January 15, 2025.
Complete your enrollment application by December 15, 2024, for a January 1, 2025, effective date.
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.
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:
- Adding a dependent or becoming a dependent
- Losing a dependent or dependent status (This is for currently enrolled customers only)
- Filed or reconciled taxes for a year that you received health insurance premium tax credits
- Change in program eligibility or amount of financial help (This is for currently enrolled customers only)
- Losing other health coverage (i.e., job loss, divorce, loss of Washington Apple Health or WSHIP coverage, etc.)
- Permanently moving from a location in the United States to Washington, or to a new county within Washington, only if you had minimum essential coverage for at least one day within the 60 days before you moved
- Permanently moving from a location outside the United States to Washington
- A change in citizenship or lawful presence status
- Getting released from jail or prison
- Tribal membership
- Gaining access to a Health Reimbursement Arrangement (HRA) through your employer. More information about HRAs can be found here
- Income changes that result in an individual being newly eligible for tax credits and cost-sharing reductions
Other qualifying life events may apply. For more information, visit HealthPlanFinder.
Visit
Molina Marketplace 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 (855) 542-1990, or you can
find a certified enrollment partner in your area who can assist you in person.
- If you apply on or before December 15, 2024, the effective date of your coverage is January 1, 2025.
- If you apply between December 16, 2024, 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
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
WAHealthPlanFinder.org and update your information.
To make a payment for your monthly premium, go to MyMolina.com, click Manage Payments, and Pay Now. We provide several payment options for your convenience. We accept Visa, MasterCard and Discover Card, electronic check, or cash at select locations. 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
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
WAHealthPlanFinder.org 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
My Molina online member account and following the prompts to make a payment, which will lead you to the Auto Pay options.
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.
Electronic Funds Transfer (EFT), checking account, or credit card, by visiting your
My Molina online member account.
Payments are due on the last calendar day of the month.
3-5 business days depending on how long it takes your bank to process the transaction.
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.
We accept only one auto-payment per month, which will be deducted from your account in full.
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.
To view the providers available in your network, visit the
Provider Online Directory.
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.
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.
Your pharmacy network is through CVS. You can see which pharmacies are available to you. Go to the
Pharmacy locator.
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.
To determine which participating provider is accepting new patients go to the
Provider Online Directory and follow the steps below.
- Select Molina Marketplace under Plan/Program located at the top of the page
- You have the option to enter “City”, “County”, “State” or “Zip Code”.
- Search options include “Browse by Category”, “Search Bar” where you can enter a name or a specialty to search for a doctor or facility.
- Select View Only “Accepting New Patients”
To determine which participating provider is in your area go to the
Provider Online Directory and follow the steps below.
- Select Molina Marketplace under Plan/Program located at the top of the page.
- You have the option to enter “City”, “County”, “State” or “Zip Code”.
- 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.
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 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!
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.
Updates to your address or contact information may impact your coverage. You will need to contact the
WAHBExchange.org to update your contact information.
Visit
mymolina.com and click on “Forgot User ID or Password?” and follow all the steps to complete the password reset.
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.
As of 12/31/2024 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.
Yes. You may select a different health plan until December 15, for a January 1 start date. Please go to
HealthPlanFinder to review your plan options.
Please go to
HealthPlanFinder 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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