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PCP visits – Your PCP will provide most of your basic health care. You will usually see your PCP for most of your routine health care needs like exams, regular check-ups, vaccinations and other treatments to keep you well. You should call your PCP whenever you have a medical question or concern. Your PCP can also refer you to the hospital or specialists when needed.

If you have a disabling condition or chronic illness, you can ask that your specialist be your PCP. Women may also choose an OB/GYN for women’s health issues. This includes check-ups, follow-up care if there is a problem, and regular care during a pregnancy. Women do not need a PCP referral to see an OB/GYN provider in our network.

Your PCP must be part of the Molina provider network. If your PCP is not in our network, you will need to choose a new doctor. Read more information on how to choose a doctor.

Specialist visits – A specialist is a doctor who provides healthcare for a specific disease or part of the body. There are many kinds of specialists. If you need care that your PCP cannot give, your PCP may send you to a specialist. They will give you what is called a referral. This will let you see the specialist if they are in the Molina provider network. If we do not have a specialist in the Molina network to provide the care you need, we will get you the care you need from a specialist outside of the Molina network. You must get approval from Molina before seeing an out-of-network specialist.

If you have a disabling condition or chronic illness, you can ask that your specialist be your PCP.

Check your Molina member handbook for more information on PCP and specialist visits

As a Molina member, you can get a physical exam from your PCP every year. This is also called an annual wellness exam. There is no cost to get this exam. Just call your PCP to set up an appointment to schedule an exam for you or your child.

An emergency is a sudden or unexpected illness, severe pain, accident or injury that could cause serious injury or death if it is not treated immediately. You are always covered for emergencies.

If you have an emergency, call 911 right away. You do not need to call Molina first. You do not need an authorization or a referral for emergency services. Calling 911 will help you get to a hospital. You can use any hospital for emergency care, even if you are in another city or state.

Tell the hospital that you are a Molina Healthcare of Virginia member. Ask them to call us at the number on the back of your member ID card.

What is a medical emergency?

This is when a person thinks he or she must act quickly to prevent serious health problems. It includes symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn’t get immediate medical attention, you believe that it could cause:

• Serious risk to your health
• Serious harm to bodily functions
• Serious dysfunction of any bodily organ or part

A medical emergency can also happen if a pregnant woman is in active labor and:

• There is not enough time to safely transfer her to another hospital before delivery
• The transfer may pose a threat to her health or safety or to that of the unborn child

What is a behavioral health emergency?

A behavioral health emergency is when a person thinks about or fears they might hurt themselves or hurt someone else in the near future. You or a family member can call our Behavioral Health Crisis Line any time you need help. You or a family member can also call this number if you or they think you’re experiencing a drug overdose.

Behavioral Health Crisis Line

• (800) 424-4518 (TTY 711)

If you have an emergency when you are away from home

You may have a medical or a behavioral health emergency away from home. You may be visiting someone outside Virginia. While traveling, your symptoms may suddenly get worse. If this happens, go to the closest hospital emergency room. You can use any hospital for emergency care. Show them your Molina member ID card or tell them you are a Molina Healthcare of Virginia member.

You can get emergency care whenever you need it, anywhere in the United States or its territories. You do not need prior authorization for emergency services. If you need an ambulance to get to the emergency room, our plan covers that. Tell your PCP and Molina about the emergency as soon as you can (with 48 hours if possible). If you need follow-up care after your emergency to get better, Molina will cover that.

Visit our “How do I?” page to read about where you should go for healthcare if you aren’t sure you have an emergency.

Read more about emergency care in your Molina member handbook.

Most people with a substance use disorder can benefit from treatment, no matter how challenging the problem may seem.

Molina provides benefits for the following services to help:

• Inpatient and outpatient treatment
• Community-based treatment
• Medication-assisted treatment (MAT)
• Peer support services
• Case management
• Referrals to opioid treatment providers (OTP)

Talk to your PCP or contact Molina and request to speak to one of our ARTS Care Managers, to determine the best treatment option for you. Search for an ARTS provider in our online provider directory. You can also contact Member Services for help finding a provider who provides these services or a referral to one of our ARTS Care Managers.

More detail on ARTS benefits can be found in your member handbook.

If you live with a behavioral health challenge, we offer the following support to help you meet your recovery goals:

• Inpatient and outpatient treatment options
• Mental Health Services (MHS), including:
  • Mental health case management
  • Therapeutic day treatment
  • Day treatment/partial hospitalization for adults
  • Intensive community treatment
  • Mental health skill-building services
  • Intensive In-Home
  • Psychosocial rehabilitation services
  • Behavioral therapy
  • Crisis Intervention and Stabilization
  • Peer support services
  • Residential treatment services

Some behavioral health services are covered through Magellan of Virginia, the Department of Medical Assistance Services (DMAS) Behavioral Health Services Administrator. If you need behavioral health services, call us and we’ll help you find a provider that can help.

You can find more information on behavioral health services in your member handbook.

Behavioral health updates starting December 1st

On December 1, 2021, Virginia Medicaid will be adding new behavioral health services to Medicaid members. 

New clinically-proven behavioral health services starting December 1, 2021 

1. Multisystemic Therapy (MST)—treatment program for members ages 12-17 with disruptive behavior, mood disorder and/or substance use. MST is delivered in home and community settings and includes family and caregivers. 
Members must have a referral for treatment of behavioral or emotional problems from the juvenile justice, behavioral health, school or child welfare systems.

2. Functional Family Therapy (FFT)—short-term treatment program for members ages 11-18 with serious emotional disturbance and substance use disorders. FFT is delivered in the member’s home. FFT also addresses parenting or caregiving challenges that affect the family unit.
Members must have a referral for treatment of behavioral or emotional problems by the juvenile justice, behavioral health, school or child welfare systems. 

For most members any transitions to new services should be seamless and you won’t have to do anything. Please call Member Services at (800) 424-4518 (TTY 711) if you have any questions about services available after December 1, 2021. We’re here Monday through Friday from 8 a.m. to 8 p.m. local time. 

Recovery Support (Peer) Navigation is for members who are coping with mental health challenges or substance use issues. When you join this program you get a certified Recovery Support Navigator (RSN) who has lived experience with mental health or addiction issues who will work as a partner in your recovery. RSNs do many things to help you, like:

• Teach you about recovery and support you with developing your own recovery and resiliency goals
• Help you live successfully in your community
• Help you identify and obtain information on community resources
• Work with you in your community, your home, or your provider setting

This flyer tells more about our Peer Recovery Navigation program and how you can join:

Peer Recovery Navigation program

Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) is a program that provides comprehensive and preventive healthcare services for children under 21. This program tries to diagnose and treat health problems as early as possible.

If you have a child under age 21, EPSDT provides appropriate preventive, dental, behavioral health, developmental and specialty services. It includes coverage for immunizations, well child visits, lead investigations, private duty nursing, personal care and other services and therapies that treat or make a condition better. It will also cover services that keep your child’s condition from getting worse. EPSDT can provide coverage for medically necessary services even if these are not normally covered by Medicaid.

Molina provides most EPSDT services (note: EPSDT services are not covered under FAMIS). However, there may be some EPSDT services, like pediatric dental care you’ll get through the Medicaid fee-for-service program. Read more about EPSDT in your member handbook. You can also call Member Services for help with these services.

Family planning services are included with your Molina standard benefits. These services include:

• Devices
• Drugs (including long acting reversible contraception)
• Supplies for the delay or prevention of pregnancy

You are free to choose your method for family planning through in-network or out-of-network providers. You do not need to get a service authorization or PCP referral for family planning services. Coverage does not include services to treat infertility or to promote fertility, nor does Family Planning Services cover payment for abortion services and no funds shall be used to perform, assist, encourage or make direct referrals for abortions.

Molina provides LTSS coverage for Cardinal Care Managed Care or Molina Medicare (HMO D-SNP) members. These services help older individuals and people living with disabilities meet their daily needs and maintain maximum independence. Your Care Manager will help you find and access services that let you live in your own home or other settings of your choice. They’re here to help you find options to improve your quality of life.

Molina covers nursing facility care for Cardinal Care members who meet the coverage criteria for that level of care. Some Cardinal Care members who qualify for nursing facility levels of care may qualify for a waiver that allows them to stay in the community and get help with their daily needs, called activities of daily living (ADL). They may have a person regularly come into their home to give them healthcare services. Molina Care Managers visit on-site at various nursing facilities. They can help you with getting nursing facility information, services, and facilitating approvals and authorizations.

Read more about Long-Term Services and Supports in your Cardinal Care Managed Care member handbook.

Pregnant women and new moms

Our Mother-Baby Connections program will guide you through early prenatal care and what to do if you think you may be pregnant. If you are pregnant, we will send text messages with health tips about each stage of pregnancy. These tips will tell you what to expect during your pregnancy, how to spot problems and how to prepare for delivery and parenthood.

Whether you are a first-time mom or already have kids, you might have questions or concerns in between doctor visits or after your baby is born. We’ll educate and support you during your pregnancy and the first year of your newborn’s life to help you and your child be as healthy as possible.

Our CenteringPregnancy program offers a supportive environment for pregnant women to share and learn together. Meet regularly with your care provider and up to 12 other pregnant members to discuss your feelings and experiences. Doctors and nurses can teach you about nutrition, how to deal with stress, caring for your infant and more.

You’ll also get extra benefits, like:

• Infant sleep sacks and diapers
• An invitation to baby showers hosted by Molina (hosted quarterly per region)
• “What to Expect When Expecting” book
• Rides to WIC appointments, Lamaze and parenting classes

Children

We’re here to help your kids grow into healthy young adults. To help them succeed, Molina members get these extra benefits:

• Annual sports physicals from a PCP for children ages 10-18
• One bicycle helmet per year for children under 18
• A backpack stocked with supplies and comfort items for children entering a new foster home

Please see your Cardinal Care member handbook for more information on these special programs.