Thank you!
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
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.
Filing a Claim: Members or Providers must promptly submit to Molina claims for Covered Services rendered to Members. All claims must be submitted in a form approved by Molina and must include all medical records pertaining to the claim if requested by Molina or otherwise required by Molina’s policies and procedures. Claims must be submitted by the Member or Provider to Molina within 365 calendar days after the following have occurred:
If Molina is not the primary payer under coordination of benefits or third-party liability, the Provider must submit claims to Molina within 30 calendar days after final determination by the primary payer. Except as otherwise provided by State Law, any claims that are not submitted to Molina within these timelines are not be eligible for payment and Provider waives any right to payment.
Molina will not deny a claim, refuse to issue or cancel a Policy of health insurance solely because the claim involves an injury sustained by a Member or Dependent as a consequence of being intoxicated or under the influence of a controlled substance or because a Member or Dependent has made a claim involving an injury sustained by the Member or Dependent as a consequence of being intoxicated or under the influence of a controlled substance, except in the case of a felony.
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 the Subscriber receives an APTC.
Medical Necessity or Medically Necessary: 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.
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 "Prescription Prior Authorization Form" and instructions for completing the request can be found here.
Molina Marketplace
Provider Phone: (833) 685-2103
Member Phone: (833)-671-0051
Fax: (833) 322-1061
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:
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.
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.
The Engage Cost Estimator Tool is for Molina Marketplace members to get a cost estimate for a procedure or service before receiving medical care from both in and out-of-network providers.
Estimates consider the plan of benefits, benefit accumulations, benefit limits, and out-of-pocket accumulations at the time of the inquiry.
No, they are only estimates and will not be the final cost. Estimates do not include unexpected charges for unexpected services/procedures or balance billing from out-of-network providers. Contact your provider for the final cost.
Estimates are not a guarantee that benefits will be provided for the service. Contact your provider to confirm services for any medical care.
In your MyMolina portal, go to the ‘Contact Us’ to find your Customer Support telephone number or send a message to us.
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.
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:
Other qualifying life events may apply. For more information, visit Nevadahealthlink.com.
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 Nevadahealthlink.com and update your information.
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.
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.
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.
To determine which participating provider is accepting new patients go to the Provider Online Directory and follow the steps below.
Yes. You may select a different health plan until December 15, for a January 1 start date. Please go to Nevadahealthlink.com to review your plan options.
Please go to Nevadahealthlink.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.
