Welcome to the Molina family.
Member Handbook
South Carolina
DATE OF ISSUANCE - January 2016
MolinaHealthcare.com
Dear Member,
Welcome to the Molina family. We know that the power to pick a health plan that is right for you
and your family is most important.
Since 1980, the Molina family has worked for better access to healthcare. We help many with
care. We work with doctors, clinics and hospitals to get you the care you need, when you need it.
We work with your community to help you with health prevention and educational activities.
Molina has health plans in many states. Molina has two offices in South Carolina. Molina also
has an award for good quality. This shows that Molina wants to offer good care to their Members.
It is important that you understand how your health plan works. This handbook is your guide to
your health care plan benefits. Please read this handbook carefully. It explains how to get health
care services. It gives you facts on the extra benefits that you get as a Molina Healthcare of South
Carolina Member. If you need help, it will tell you who to call.
Our commitment is to keep helping in the areas we serve. We look forward to serving you.
Thank you for picking Molina Healthcare of South Carolina.
Sincerely,
Tom Lindquist
President, Molina Healthcare of South Carolina
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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Non-Discrimination Notification
Molina Healthcare of South Carolina
Medicaid
Molina Healthcare of South Carolina (Molina) complies with all Federal civil rights laws that
relate to healthcare services. Molina offers healthcare services to all members without regard
to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat
them differently because of race, color, national origin, age, disability, or sex. This includes
gender identity, pregnancy and sex stereotyping.
To help you talk with us, Molina provides services free of charge:
• Aids and services to people with disabilities
o Skilled sign language interpreters
o Written material in other formats (large print, audio, accessible electronic
formats, Braille)
• Language services to people who speak another language or have limited English skills
o Skilled interpreters
o Written material translated in your language
o Material that is simply written in plain language
If you need these services, contact Molina Member Services at (855) 882-3901,
TTY/TDD: 711.
If you think that Molina failed to provide these services or treated you differently based on your
race, color, national origin, age, disability, or sex, you can file a complaint. You can file a
complaint in person, by mail, fax, or email. If you need help writing your complaint, we will help
you. Call our Civil Rights Coordinator at (866) 606-3889, or TTY, 711. Mail your complaint to:
Civil Rights Coordinator
200 Oceangate
Long Beach, CA 90802
You can also email your complaint to [email protected]. Or, fax your
complaint to (877) 823-5961.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights. Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html. You can mail it to:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
You can also send it to a website through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.
If you need help, call 1-800-368-1019; TTY 800-537-7697.
Molina Healthcare Notice 1557 - SC Medicaid_no logo
Updated 10.14.16
Non-Discrimination Tag Line– Section 1557
Molina Healthcare of South Carolina, Inc.
Spanish
Arabic
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-855-882-3901 (TTY: 711).
‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬
.)117 :YTT) :‫ (رقم هاتف الصم والبكم‬1093-288-558-1
Portuguese
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue
para 1-855-882-3901 (TTY: 711).
Russian
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-855-882-3901 (телетайп: 711).
Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-855-882-3901 (TTY: 711).
Brazilian
Portuguese
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue
para 1-855-882-3901 (TTY: 711).
Mandarin
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-882-3901
（TTY：711）。
RALRINNAK: Falam (Laizo) `ong na thiam asile, man lo tein `onglettu bawmh le
hna`uan seknak nangmah hrangah aum. ah ko aw 1-855-882-3901 (TTY:711).
Falam
Hindi
ध्यान दें: यदद आप ह द
िं ी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-8823901 (TTY: 711) पर कॉल करें ।
Korean
Chin
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-855-882-3901 (TTY: 711) 번으로 전화해 주십시오.
THEIHDING: Lai holh na thiam asi ah cun, holh let tu a lak in kan in hlan piak lai. 1-855882-3901 (TTY: 711) ah in rak hlat te.
French
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-855-882-3901 (TTY : 711).
Karen
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Amharic
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት
ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-855-882-3901 (መስማት ለተሳናቸው: 711).
Burmese
သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊
သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-855-882-3901 (TTY: 711) သုိ႔ ေခၚဆိုပါ။
MHSC – 1557 tag lines.v3
Created 10/20/16
Welcome to Molina Healthcare of South Carolina!
Our mission is to provide quality health services to individuals and families covered by
government programs. Our service area includes all 46 counties of South Carolina. As a Member,
you are eligible for all your Medicaid benefits plus a 24-hour Nurse Advice Line service available
to answer your health questions.
You will get your Molina Member identification (ID) card about two (2) weeks after your effective
date. If you have not received your (ID) card yet, it will arrive soon. Take your card to all your
doctor visits. Show your card to your doctor’s staff.
This handbook is your guide to your Molina benefits. It will tell you about the things you need to
do as a Member. It tells you how to get health care services. It tells you about the extra benefits that
you get as a Member. If you need help, it tells you who to call.
If you need help as you read this, please call Member Services. We can answer any questions
you may have. We can explain any details to you in English. We can also explain information in
any other language. We may also have the printed materials in other languages. If you have trouble
seeing or hearing, we can give you extra help.
You can call Member Services at 1-855-882-3901 (Hard-of-Hearing TTY Relay Service: 711).
We’re open Monday through Friday from 8:00 a.m. to 6:00 p.m.
You can also write to us at:
Molina Healthcare of South Carolina
Attention: Member Services
P.O. Box 40309
North Charleston, SC 29423-0309
Please visit our website for up-to-date Member
information, health education, a list of Providers, and
much more at: www.MyMolina.com.
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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These icons will help you as you read
the handbook.
They will help you get the most out of being a Molina Healthcare of South
Carolina Member.
Important Information
This icon shows information you will need to use your benefits.
Medical Home
The first thing to do in order to take care of your health is to pick a Primary Care
Provider (PCP). This is called finding a medical home. This icon shows you how to
find a medical home.
Nurse Advice Line
This icon is there to remind you that the 24-Hour Nurse Advice Line is ready to
help if you have any medical questions or problems.
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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Certificate of Coverage
This Certificate of Coverage (Certificate) is issued by Molina Healthcare of South Carolina
(MHSC). Molina is a health maintenance organization, hereinafter referred to as “Your Health
Care Plan”. In consideration of the Member’s enrollment, MHSC shall provide and/or arrange for
covered health care services to the Member in accordance with the provisions of this Certificate
of Coverage.
Read the whole Certificate thoroughly. Many parts of this Certificate are related to other parts.
You will have a better understanding if you read all the parts, not just one or two items.
Many words used in this Certificate have special meanings. Such words will begin with capital
letters, and the meaning will be explained to you. By using these definitions, you will understand
your benefits better.
This Certificate may be subject to amendment, modification, or termination by mutual
agreement between MHSC and the South Carolina Department of Health and Human
Services (SCDHHS) without the consent of any Member. Members will be notified of such
changes as soon as possible after they are made. By choosing health care coverage under MHSC,
Members agree to all the terms and conditions in this Certificate.
IN WITNESS WHEREOF, MHSC has caused this Certificate of Coverage to be executed by its
duly authorized officer on the date indicated below, under which Certificate coverage will begin
on the Effective Date indicated on the Member’s MHSC identification card.
Molina Healthcare of South Carolina
President
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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Table of Contents
Telephone Numbers.......................................................................................................................................7
Member Services Department .....................................................................................................................9
Translation Services.....................................................................................................................................9
Healthy Connections – Renew or Lose It.......................................................................................................9
Member Self Service ...................................................................................................................................9
24-Hour Nurse Advice Line .........................................................................................................................10
Identification (ID) Cards ................................................................................................................................10
Your Medical Home .......................................................................................................................................11
Choosing a Primary Care Provider (PCP) ......................................................................................................11
Changing Your PCP ......................................................................................................................................12
Non-Par Providers and Services....................................................................................................................12
Getting Medical Services .............................................................................................................................13
Emergency Services ....................................................................................................................................13
After-Hours or Non-Emergency Care ............................................................................................................14
Urgent Care..................................................................................................................................................14
Hospital Care................................................................................................................................................15
Mental Health and Substance Abuse Services ..............................................................................................15
New Member Information ............................................................................................................................15
Second Opinion............................................................................................................................................15
Services Covered by Molina Healthcare of South Carolina ................................................................ 17
Co-Payments................................................................................................................................................23
Molina Extra Benefits....................................................................................................................................23
Services Outside the Core Benefits...............................................................................................................24
Prior Approval................................................................................................................................................25
Managed Care Enrollment of Newborns .......................................................................................................25
Getting Prescriptions.....................................................................................................................................26
How to Obtain a Prescription Drug................................................................................................................26
What is Covered?..........................................................................................................................................26
Prior Approval...............................................................................................................................................26
Injectable and Infusion Services....................................................................................................................26
Step Therapy................................................................................................................................................27
Medications Not on Your Health Plan’s Preferred Drug List............................................................................27
Continuation of Medications.........................................................................................................................27
Brand Name Drugs Instead Of Generic Forms of the Same Drug...................................................................27
Additional Benefits................................................................................................................ 28
Non-Discrimination of Caregivers.................................................................................................................28
Transportation Services................................................................................................................................28
Back Transfers..............................................................................................................................................29
Transportation for Out-of-State Medical Services..........................................................................................29
Case Management .......................................................................................................................................29
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Well Child Program.......................................................................................................................................30
Women, Infants and Children Program (WIC) ................................................................................................30
Motherhood Matters Pregnancy Program......................................................................................................30
How Molina Healthcare of South Carolina Pays for Your Care ........................................................................31
What If I Get a Bill? ......................................................................................................................................31
Evaluating New Technology .........................................................................................................................31
Your Membership Rights ..............................................................................................................................32
Your Membership Responsibilities ..............................................................................................................34
Your Privacy ..................................................................................................................................................34
Your Protected Health Information (PHI).........................................................................................................34
Why Does Molina Use or Share Our Member’s PHI?......................................................................................34
When Does Molina Need Your Written Authorization (Approval) to Use or Share Your PHI?..............................34
What Are Your Privacy Rights? .....................................................................................................................35
How Does Molina Protect Your PHI? .............................................................................................................35
What Must Molina Do By Law? ....................................................................................................................35
What Can You Do If You Feel Your Privacy Rights Have Not Been Protected? .................................................35
Notice of Privacy Practices ..........................................................................................................................36
Why Does Molina Use or Share Your PHI? .....................................................................................................36
When Can Molina use or Share Your PHI Without Getting Written
Authorization (Approval) From You? ..............................................................................................................37
When Does Molina Need Your Written Authorization (Approval) to Use or Share Your PHI?..............................37
What Are Your Health Information Rights? ..................................................................................................38
You Have The Right To: .................................................................................................................................38
What Can You Do if Your Rights Have Not Been Protected? ...........................................................................38
What are the Duties of Molina? ....................................................................................................................39
This Notice is Subject to Change ..................................................................................................................39
Appeals and Grievances................................................................................................................................40
Enrollee Services and Hotline Information.....................................................................................................40
Grievance Procedure....................................................................................................................................40
Appeals........................................................................................................................................................41
State Fair Hearing ........................................................................................................................................42
Membership Termination .............................................................................................................................42
Ending Your Membership .............................................................................................................................42
Choosing a New Plan ...................................................................................................................................43
Can Molina Healthcare of South Carolina End My Membership? ...................................................................43
Fraud and Abuse ...........................................................................................................................................44
Advance Directives .......................................................................................................................................45
Frequently Asked Questions Regarding Advanced Directives:........................................................................46
Glossary/Definitions .....................................................................................................................................46
Molina Healthcare of South Carolina Member Grievance Request Form....................................................49
Medical Appeal Request................................................................................................................................51
How to Pick a PCP – Checklist......................................................................................................................53
First Visit - Check List ..................................................................................................................................54
Your Health Providers....................................................................................................................................55
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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Telephone Numbers
Member Services
1-855-882-3901
Hard-of-Hearing TTY Relay Service: 711
Español 1-855-882-3901
24 Hour Nurse Advice Line
1-888-275-8750
Hard-of-Hearing TTY Relay Service: 711
Español 1-866-648-3537
South Carolina Department of Health and
Human Services (SCDHHS)
1-888-549-0820
Hard-of-Hearing TTY Relay Service: 711
South Carolina Healthy Connections Choices
1-877-552-4642
Hard-of-Hearing TTY Relay Service: 711
(your Medicaid eligibility)
Care Management
Fraud and Abuse Hotline
(Confidential Compliance Hotline – SCDHHS)
WIC Care Line
1-855-882-3901
Hard-of-Hearing TTY Relay Service: 711
Español 1-855-882-3901
1-888-364-3224
1-800-868-0404
Childhood Lead Poisoning Prevention
Program at South Carolina DHEC
1-803-898-3432 (DHEC)
Member Self Service Website
www.MyMolina.com
Espanol www.MiMolina.com
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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HEALTHY CONNECTIONS; RENEW IT OR LOSE IT!
To keep your health plan, you must renew your coverage every year to keep your SC Healthy
Connections coverage.
We want you to keep your family in the Healthy Connections Programs. To do so, you have to make sure you
renew your Medicaid benefits every year.
When you have been a Member of the Medicaid program, the South Carolina Department of Health and
Human Services (SCDHHS) will check to see if you still qualify for Medicaid. You will get a package from them
asking you for some information. Put this package in a safe place. DO NOT THROW IT AWAY. It is important
that you complete the necessary information. When you are done make sure to send it back to SCDHHS as soon
as you can.
If you do not do this, SCDHHS will end Medicaid for you and your family.
When SCDHHS makes the decision that you qualify for Medicaid they will send you Healthy Connections
Choices Annual Right to Change Packet. The Annual Right to Change letter will say it has been one year since
you joined Molina Healthcare of South Carolina. If you want to keep being part of Molina Healthcare of South
Carolina you do not have to do a thing.
If you need help, please call our Member Services Department at 1-855-882-3901. Remember you have to
complete all information and send it back to SCDHHS.
If you have not received your packet or lost it, you can call 1-888-549-0820 today. When you have filled it out
you can mail it to :
SCDHHS - Central Mail
P.O. Box 1000101
Columbia, SC 29202-3101
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
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If you have any problems with this or any other health care plan information, please call our Member
Services Department at 1-855-882-3901. TTY Relay Service is found by dialing 711. We can help
you in English or in your primary language. We have these materials printed in other languages as
well. We can also help you if you are visually or hearing impaired.
Member Services Department
Our Member Services Department is here to help you with any questions you may have. Member Services
representatives can help you:
•
•
•
•
•
Understand your benefits
Update your contact information
Request a new ID card
Pick a Primary Care Provider (PCP)
Assist with scheduling non-emergent transportation
You can reach the Member Services Department by calling
1-855-882-3901 (TTY Relay Service 711) from 8:00 a.m. to 6:00 p.m.
Monday through Friday. You can also go to the web to learn about your
benefits at www.MolinaHealthcare.com.
Translation Services
Our Member Services Department also provides interpretive services to all non-English speaking Members and
potential Members when a staff Member is not available to translate in the caller’s language. These services are
provided at no cost. If you are non-English speaking or need something in Braille, large print or audio,we can
help. We have translation and alternative format services (including sign language). We can even arrange to have
a translator or sign language interpreter at your appointments. Just give us a call. There is no cost to you for this.
If you call us after business hours with a non-urgent request, leave a message. If you have an urgent need, please
call our Nurse Advice Line 24 hours a day, 7 days a week for translation assistance.
If the caller has an interpreter available, the interpreter can be used.
Should you need to use translation services, please call Member Services Department at 1-855-882-3901 (TTY
Relay Service 711) from 8:00 a.m. to 6:00 p.m.
Member Self Service
Members can access many services through www.MyMolina.com. Member Self Service is available 24 hours a
day, 7 days a week. You can use Member Self Service to:
•
•
•
•
•
Change your address or phone number
Find a contracted health care Provider
Change your Primary Care Provider (PCP)
Request a new ID card
File a grievance
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
9
You can go to Member Self Service through the Molina Healthcare of South Carolina website.
Visit www.MyMolina.com and click on “Register Now” to create an account.
Molina Healthcare of South Carolina’s office is closed on the following days:
•
•
•
•
New Year’s Day
Martin Luther King, Jr. Day
Memorial Day
Independence Day
•
•
•
•
Labor Day
Thanksgiving Day
Day after Thanksgiving
Christmas Day
If a holiday falls on a Saturday, we will be closed on the Friday before. If a holiday falls on a Sunday, we will
be closed the Monday after.
Welcome to Molina Healthcare!
4105 Faber Place Drive, STE 120
Charleston, SC 29405
24-Hour Nurse Advice Line
December 17, 2013
You can call the Nurse Advice Line 24 hours a day, 7 days a week. The Nurse Advice Line will answer your
Tymesha
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1204 Feaster St
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• Thank
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concern
• Visit our website for more information: www.MolinaHealthcare.com
REMOVE CARD ALONG PERFORATION
Identification (ID) Cards
Member: TYMESHA L EPPS
ID #: 6780803934
DOB: 11/03/2007
Member: DESTINY R SIMS
Program: SC Medicaid
PCP Name: ROBERT M WENTZ
PCP Phone: (864) 429-8029
PCP Location: 801 W MAIN ST
24hr Nurse Help Line: (888) 275-8750 or (866) 648-3537 (Espanol) - Member Services: (855) 882-3901
RxPCN: ADV
Program: SC Medicaid
PCP Name: OMRI K WEBB
PCP Phone:
PCP Phone: (864) 427-9045
PCP Location:
PCP Location: 429 E MAIN ST
PCP Practice Name:
RxBIN: 004336
ID #: 7630301457
DOB: 06/29/2000
RxGRP: Rx0860
24hr Nurse Help Line: (888) 275-8750 or (866) 648-3537 (Espanol) - Member Services: (855) 882-3901
RxBIN: 004336
RxPCN: ADV
RxGRP: Rx0860
www.MolinaHealthcare.com · Molina Healthcare of South Carolina Member Services 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711)
10
Always Keep Your ID Cards With You
You will need both your Molina and Medicaid ID cards each time you get medical services. This means that you
need to present both ID cards when you:
•
•
•
•
See your Primary Care Provider (PCP)
See a specialist or other Provider
Go to an emergency room
Go to an urgent care facility
•
•
•
•
Go to a hospital for any reason
Get medical supplies
Get a prescription
Have medical tests
Call the Member Services Department as soon as possible at 1-855-882-3901
(Hard-of-Hearing TTY Relay Service 711) if:
• You have not received your ID card yet
• Any of the information on the ID card is wrong
• You lose your ID card or if the ID card gets stolen
Make sure the right Primary Care Provider (PCP) shows on your ID card. Call us if the PCP you are
seeing is not the PCP on your ID card. We will correct your card and send you an updated ID card. If
you want to see a different PCP other than the one on your ID card, visit www.MyMolina.com. You
can call Member Services for help picking a different Provider.
Your Medical Home
One of the first steps to take care of your health is to pick a medical home. When you pick a
Primary Care Provider (PCP), you choose a medical home. A PCP can be a general practice
doctor, family medicine doctor, internal medicine doctor, pediatrician, or OB/GYN.
Your PCP is the doctor who will help you with most of your medical needs. Your PCP will give you care and
medical advice. Your PCP will refer you to a specialist if you need one. When you pick a PCP who meets
your needs, you can begin building a lasting relationship and trust that will ensure quality healthcare for years
to come.
Choosing a Primary Care Provider (PCP)
You have to pick a Primary Care Provider (PCP) from the Provider Directory. Your PCP is your
personal Provider.
Your PCP can be an individual doctor. It can be a group of doctors. It can be a family/general practitioner, a
specialist in internal medicine, a pediatrician (for children), an OB/GYN (for pregnant women), advanced
practice nurse, or a health clinic (Rural Health Clinic – RHC – or Federally Qualified Health Center - FQHC).
Your PCP will work with you to take care of your health. Your PCP will treat you for most of the routine health
care you need. Your PCP will send you to other doctors (specialists) or admit you to the hospital when necessary.
There may be a reason that a specialist may need to be your PCP. If you and/or your specialist think they should
be your PCP, you should call Member Services to talk about it.
The “How to Pick a PCP Checklist” attached to the back cover of this handbook will help you select a PCP.
The names of contracted PCPs are in the Provider Directory. You can see the Provider Directory on the Internet
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at www.MolinaHealthcare.com. If you would like to request a mailed copy of the Provider Directory, or if you
need help picking a PCP, call Member Services at 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711).
If you do not choose a PCP, we will choose one for you. When we make this choice for you, we will take your
home address, the language you speak, and the Providers that your family Members see into consideration.
However, it is better if you pick your own PCP. You can make the best decision.
Once you have a PCP, you need to plan a visit, even if you are not sick. When you visit, you will get to know your
doctor. You can ask questions to help you know your doctor better. You can reach your PCP by calling the PCP’s
office. Your PCP’s name and telephone number are shown on your ID card.
If you want to find out more about your PCP or other plan doctors or Providers, go to our website at
www.MolinaHealthcare.com or call Member Services. We can tell you more about your Provider. We can tell you
about their special qualifications, where they went to medical school, where they completed their medical training
and any board certifications they have. You can also get information on the languages your Provider speaks.
You can view the Provider Directory online. Did you know the Internet is free at most public libraries? There are
even companies that let you to set up free email accounts. If you need help using the Internet, ask your librarian.
If you would like printed copies of any of the information you see on our website, please call Member Services.
The information is available in English but can be provided in any other language at no cost to you.
Changing Your PCP
You may change your PCP through Member Self Service by visiting www.MyMolina.com or you can call the
Member Services Department.
We will send you a new ID card to let you know that your PCP has been changed and the date you can start
seeing the new PCP.
The names of the doctors in your health plan are in the Provider Directory. You can look up the PCP
if you have a printed copy of the Provider Directory. You can also look up the PCP on our website at
www.MolinaHealthcare.com or you can call Member Services Department at 1-855-882-3901
(Hard-of-Hearing TTY Relay Service 711) for help.
Non-Par Providers and Services
If your PCP wants you to see a doctor that is not part of Molina Healthcare of South Carolina’s network of
Providers, this is called a non-par Provider. Your PCP will need to call us for approval if you or your PCP wants
to use a non-par Provider. We offer you a network of Providers that includes doctors and hospitals that provide
most medical services.
Your PCP can ask that you receive services from a non-par Provider. However, if the services are available within
our network of Providers, we may ask that you use one of our Providers.
If your PCP’s request for a non-par Provider is denied, you may file an Appeal. If the Appeal is denied you may
request a State Fair Hearing with SCDHHS. Note: a State Fair Hearing request may only be filed after the appeals
process with Molina Healthcare of South Carolina has been exhausted. More information about Appeals and
State Fair Hearings can be found in the Appeals and State Fair Hearings sections of this handbook.
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Getting Medical Services
You must get services by one of our facilities and/or Providers. The times you can use Providers that are not in
our network is for:
• Emergency services
• Indian Health Service Center (Catawba Service Unit)
• Federally Qualified Health Centers/Rural Health Clinics
• Public Health Service Centers including:
• Qualified Family Planning Providers
• Community Mental Health Centers
• Department of Alcohol and Other Drug Abuse Services (DAODAS)
• A non-par Provider that Molina Healthcare of South Carolina has approved you to see
You can visit our website at www.MolinaHealthcare.com to get up to date information of the Providers you can
use to receive services. If you are not in the plan service area and you need non-emergency medical care, the
Provider must first call us to get approval before any services are provided. If you are away from the plan service
area and need emergency care, go to the nearest Emergency Room (ER). You have the right to go to any facility
that provides emergency services.
Emergency Services
Emergency services are for medical problems including some behavioral health and substance abuse problems
(like drugs and alcohol) you think are so serious they must be treated right away by a doctor. Emergency services
are covered at any facility or Provider who offers emergency care. Emergency care is available 24 hours a day,
7 days a week.
Some cases of when emergency services are needed are:
• Miscarriage/pregnancy with vaginal bleeding
• Seizures or convulsions
• Unusual or excessive bleeding
• Unconsciousness
• Overdose / Poisoning
• Behavioral Health emergencies such as psychiatric
disturbances and/or symptoms or feelings so
serious you are not able to cope
• Severe burns
• Broken bones
• Chest pain
• Difficulty breathing
If you are not sure if you need to go to the ER, call your PCP or the 24-Hour Nurse Advice Line at
1-888-275-8750 (Hard-of-Hearing TTY Relay Service 711). Your PCP or the Nurse Advice Line can
talk to you about your medical problem and give you advice on what you should do.
If you need emergency services:
• Go to the nearest hospital emergency room or other appropriate setting. Be sure to tell them that you are a
Member of Molina Healthcare of South Carolina, and show them both of your ID cards (Molina and Medicaid).
• If the Provider who treats you for an emergency thinks you need other medical care, they should call us.
• After an ER visit, call your PCP to make an appointment for follow-up care. Do not go to the emergency
room for follow-up care.
• Post-stabilization services are Medicaid-covered services relating to the emergency that you get after you are
stabilized to help you stay stable, improve or resolve the condition. You can get post-stabilization care and
coverage 24 hours a day, 7 days a week.
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After-Hours or Non-Emergency Care
If your doctor’s office is closed or they cannot see you right away, take these steps:
1. Call your PCP for advice. If the Provider’s office is closed, they have someone available
24 hours a day, 7 days a week who will let you know what to do.
2. If you cannot reach your Provider’s office, call the 24-Hour Nurse Advice Line at
1-888-275-8750, (Hard-of-Hearing TTY Relay Service 711). Nurses are always ready to answer your
questions.
3. Go to an urgent care center listed in the Provider Directory. You do not need permission from a Provider
to go to an urgent care center. If you visit an urgent care center, always call your PCP after your visit to
schedule follow-up care.
Call 911 or go to the nearest Emergency Room. 911 is the local emergency telephone system available 24-hours a
day, 7 days a week.
Non-emergency treatment for an illness or injury: Call your PCP to make an appointment.
Routine care such as a physical exam, wellness visit or immunizations: Call your PCP to make an appointment.
Family Planning and Women’s Health Services: You do not need a referral to get Women’s Health or Family
Planning Services. You can go to your PCP, a women’s healthcare Provider listed in the Provider Directory,
certified nurse widwife, or qualified family planning Provider to receive these services.
Specialist appointments: Call your PCP first. Your PCP will send you to another doctor, a specialist, if you
need one.
24-Hour Nurse Advice Line Services: As a Member of Molina Healthcare of South Carolina, you can call our
24-Hour Nurse Advice Line services, 24 hours a day, 7 days a week. There is no cost to you! They can answer
questions that you have about your health.
For example, you can call:
• When your child is sick and you are not sure what to do
• If you are not sure where to go for care
• If you have a medical question after your health care Provider’s normal business hours
• To understand the types of treatments you can choose
• For advice on taking medicine safely
• To teach you about important health screenings and shots
• For tips on eating healthy and staying fit
• To learn how to save money on prescriptions
A registered nurse will answer the phone lines. Many of the nurses speak both English and other languages.
Call Molina Healthcare of South Carolina’s 24-Hour Nurse Advice Line at 1-888-275-8750, (Hearing Relay
Service 711). Please keep in mind that our nurses cannot diagnose problems or recommend specific treatment.
They are not a substitute for your doctor’s care.
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Urgent Care
Urgent care is when you or a family Member need care, treatment, or advice within 48 hours. Call your PCP’s
office and explain why you need urgent care. Your PCP will see you or tell you what to do for your care.
Primary Care Practitioner (PCP)
Types of Care for Appointment
Appointment Wait Time (Appointment Standards)
Routine Primary Care
Within 4 weeks
Urgent Care
Within forty-eight (48) hours
Routine Specialist Care
Within 12 weeks
Emergency Care
Walk-in Patients
Office Wait Times
Immediately upon presentation at treatment site. Access by telephone
for emergent medical conditions.
Should be seen if possible. Urgent needs must be seen within fortyeight hours of walk-in. Non-urgent needs must be seen within routine
care guidelines above.
Within forty-five (45) minutes for a scheduled appointment of a
routine nature
After Hours Care
After-Hours Instruction/Standards
After hours emergency instruction
“If this is an emergency, please hang up and dial 911”
After-Hours Care
Available by phone twenty-four (24) hours/seven (7) days
Behavioral Health
Types of Care for Appointment
Appointment Wait Time (Appointment Standards)
Non-life Threatening Emergency Care Within six (6) hours of request
Urgent Care
Within forty-eight (48) hours
Routine Care
Within ten (10) calendar days
Hospital Care
Molina Healthcare of South Carolina covers services that are medically necessary. Some examples of hospital
services are:
• Hospital admission (going to a hospital)
• The use of hospital for a medical operation (surgery)
• The use of hospital medical equipment (like an MRI or CT scan)
There are some services that Molina Healthcare of South Carolina must approve before you can get them. Your doctor
will need to send Molina Healthcare of South Carolina a prior authorization request. If you need to be admitted to
a hospital, your doctor will send Molina Healthcare of South Carolina a request along with information on why you
need to use a hospital. This is just part of the process to show what you need and that the care is medically necessary.
Non- Emergency Hospital Admissions
If the request for admission is not approved, you or your doctor can appeal. Please see the Grievance and
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Appeals section in this handbook.
Mental Health and Substance Abuse Services
If you need mental health and/or substance abuse services, call the Member Services Department for
information at 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711) or you may self-refer directly to a
South Carolina Department of Mental Health, (DMH) or the South Carolina Department of Alcohol and Other
Drug Abuse Services (DAODAS). Please see your Provider Directory or call our Member Services Department
for the names and telephone numbers of the facilities near you. You can also look at the Provider Directory
online at www.MolinaHealthcare.com.
New Member Information
If you were on Medicaid fee-for-service or with another health plan the month before you became a Member
with Molina Healthcare of South Carolina, and have health care services already approved and/or scheduled,
you should call the Member Services Department right away. Call today or as soon as possible.
Sometimes, for a brief time after you sign up, we will allow you to get care from a Provider that is not a network
Provider. Also, we may let you get services that were previously authorized but you must call Molina Healthcare
of South Carolina before you receive the care. If you do not call us, you may encounter difficulty being able to
get the care. For example, you need to call the Member Services Department if you have the following services
already approved and/or scheduled:
• Inpatient/outpatient surgery
• Appointment with a primary or specialty Provider
• Chemotherapy or radiation treatments
• Treatment following discharge from the hospital in the last 30 days
• Medical equipment
• Services you receive at home, including home health, therapies, and nursing
• Organ, bone marrow, or hematopoietic stem cell transplant
• Non-routine dental or vision services (for example, braces or surgery)
Also, it is very important to call Member Services if you are pregnant. That way, we can work with you to ensure
you continue to receive proper prenatal care for you and your baby.
Second Opinion
You are entitled to a second opinion. If you want to know what another doctor says about your health problem,
you may get a second opinion at no cost to you. To obtain a second opinion, call Member Services to get help
with this process.
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Services Covered by Molina Healthcare of South Carolina
SERVICES
Ambulance Services
Ancillary Medical
Services
Chiropractic Services
COVERAGE
Covered.
Emergency transportation given by:
• Ambulance
• Air ambulance
Covered.
LIMITS/
EXCLUSIONS
Covered.
Limited to 8 visits
Limited to manual manipulation of the spine per year.
using the hands to put the bones of the spine
back in line.
Communicable Disease Covered.
Services
Exams and reviews including but not limited to:
• Taking steps to find out what’s wrong with
you and treat you
• Contact tracing
• Counseling and health education
• Directly Observed Therapy (DOT) for
tuberculosis (TB) cases. Help controlling
and preventing diseases such as TB,
syphilis, and other sexually transmitted
infections (STIs) and HIV/AIDS
Disease Management
Covered.
This includes keeping track of any medical
conditions/diseases, and educating you
regarding available treatment options.
Durable Medical
Covered when medically necessary.
Equipment and Supplies Equipment may require prior approval from
your doctor.
Medically necessary equipment and supplies,
including:
• Medical products
• Surgical supplies
• Wheelchairs
• Traction equipment
• Walkers
• Canes
• Crutches
• Ventilators
• Prosthetic devices
• Orthotic devices
• Oxygen
• Hearing aids and accessories
• Diabetes supplies
• Incontinence supplies
• Any other items when ordered by a
doctor as medically necessary
COPAYMENT
*NOTE: These
services can
also be received
at Department
of Health and
Environmental
Control (DHEC).
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SERVICES
Emergency Medical
Services
COVERAGE
Covered.
Call your Primary Care Provider (PCP) as
soon as possible.
All emergency services are covered. You do
not need an OK from us for any emergency
services.
Vision Services
Covered.
Family Planning
Covered.
This includes medical visits for birth control:
• Teaching you about family planning
• Counseling
• Birth control drugs and supplies
• Pregnancy tests
• Lab tests
• Tests for sexually transmitted
infections (STIs)
• Sterilization
• Teen pregnancy prevention program
Hearing Exams, Hearing Covered for Members under age 21.
• Hearing exams
Aids and Hearing Aid
• Hearing aids and supplies
Accessories
Newborn Hearing
Covered for Members up to six months of
Screening
age in either in-patient or out-patient setting
without prior authorization.
Must be performed within the first six (6)
months of life.
Home Health Services
Covered.
Medical visits that take place in the home
from time to time which can include:
• Skilled nursing
• Home health aides
• Medical supplies and equipment fit for
use in the home
• Physical, occupational and speech
therapy
• Supplies ordered by a doctor
LIMITS/
EXCLUSIONS
COPAYMENT
We do not cover:
• Surgery
to reverse
sterilization
• Hysterectomy
for
sterilization
reasons
Only for children
under 21 years
of age.
Limited to 50 visit
per year.
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LIMITS/
EXCLUSIONS
Private rooms
Hospitalization including Covered.
are not covered
Services normally
All hospital services must be ordered by a
Provided by the Hospital doctor. These hospital services may include: unless medically
• A semi-private room
necessary.
• Maternity services
• Special treatment rooms
• Operating rooms
• Supplies
• Medical tests and X-rays
• Drugs the hospital gives you during
your stay
• Giving you someone else’s blood
• Radiation therapy
• Chemotherapy
• Dialysis treatment
• Meals and special diets
• General nursing services
• Anesthesia
• Anesthesia for dental procedures when
it is an emergency
• Setting up a plan for when you leave the
hospital (this includes future care if you
need it)
• Rehab in the hospital
Hysterectomies,
Covered when they are non-elective and
We do not cover:
medically necessary.
• Surgery
Sterilizations and
to reverse
Abortions
sterilization
• Hysterectomy
for sterilization
reasons
• Abortion
services
(unless they
are needed to
save a mother’s
life or to end
a pregnancy
caused by rape
or incest)
Laboratory Exams
Covered.
and X-Rays
Medically necessary lab and X-ray services
ordered by your Provider.
SERVICES
COVERAGE
COPAYMENT
$25.00 per
hospital
admission.
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SERVICES
COVERAGE
Maternity Services
LIMITS/
EXCLUSIONS
COPAYMENT
Covered. This may include the following
services:
• Doctor visits and all expert care for
pregnancy, problems that have to do
with pregnancy and after-delivery care
when medically necessary
• Services you get from a certified nursemidwife
• Tests you need such as sonograms
• HIV testing, treatment and counseling
(A pregnant Member may refuse to take
an HIV test)
• Birthing center services
• Vaginal childbirth and Cesarean section
(C-section)
• Newborn hearing screenings
Limited to the first
Long Term Care
Covered for first 90 days (or until
90 days in a row.
Facilities/Nursing Home disenrollment from plan) when you are
approved for and admitted to a long-term
• Maximum
Facilities
limit of
care facility.
covered days
is 120
Outpatient Pediatric
AIDS Clinic Services
(OPAC)
Covered.
Services for HIV-related and
exposed children and their families
including:
• Specialty care
• Consults
• Counseling
• Clinical and lab tests
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SERVICES
Outpatient Services
Rehabilitation Therapy
Audiological Services
Prescription Drugs
COVERAGE
Covered.
Services must be ordered by a doctor and
may include:
• Care to prevent illness
• Care to treat your health issue
• Rehab
• Surgical care
• Emergency care
• Psychiatric assessment
• Substance abuse assessment
• Treatment of renal disease
• Neurodevelopmental or mental
developmental assessment and testing
• Dialysis
• Emergency room use
• Drugs ordered by a doctor
• Giving you replacement blood
• Services to prevent problems or find out
what is wrong with you
• Surgery without an overnight
hospital stay
• Sterilization
Services include: physical therapy,
occupational therapy, speech therapy,
audiology and nursing services. Children
who may have medical risk factors can
have their:
• Health status assessed
• Risk factors identified
• Goal-oriented plan of care written or
changed
Covered only for children under 21 years of
age. Services include:
• Examinations
• Fittings and related audiology services
• Diagnosis, screening, preventive and
corrective services for Members with
hearing disorder or to determine
hearing disorder
Covered.
LIMITS/
EXCLUSIONS
Neurodevelopmental
or mental
developmental
assessments and
testing are only for
eligible Members
under 21 years of age.
COPAYMENT
$3.40 per
visit (except
emergency room
visits).
Only covered for
children under 21
years of age.
An approval from
Molina is required
for some drugs.
Some drugs are not
covered, check the
Preferred Drug List
(PDL).
$3.40 per
prescription /
refill.
$3.40 per
prescription /
refill excludes
contraceptives.
Copay only
applies to
Members aged 19
and older who are
not pregnant.
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SERVICES
Preventive and
Rehabilitative Services
for Primary Care
Enhancement
COVERAGE
Covered.
Members who may have medical risk factors
get their:
• Health status assessed
• Risk factors identified
• Goal-oriented plan of care done or changed
Physician Services
Covered.
This includes services provided by a
Physician or Nurse Practitioner or Rural
Health Clinic – RHC or Federally Qualified
Health Center – FQHC.
Psychiatric Assessment/ Covered.
Treatment Services
Psychiatric assessment services that you may
get in your doctor’s office. The following
visits may be given by the following types of
Providers:
• Psychiatric interview exam provided by
a doctor and private psychiatrist.
• Psychiatric interview by a private
psychiatrist only.
• Behavioral health services given in the ER.
Transplant Services
Covered.
Must have approval from a doctor before
transplant can be performed. Types of
transplants include:
• Kidney
• Corneal
• Bone Marrow (Autologous Inpatient
and Outpatient, Allogeneic Related and
Unrelated, Cord, and Mismatched)
• Pancreas
• Heart
• Liver
• Liver with Small Bowel
• Liver/Pancreas
• Liver/Kidney
• Kidney/Pancreas
• Lung and Heart/Lung
• Multivisceral
• Small Bowel
Well-Care Visits for
Covered only for children through the
month of their 21st birthday.
Children including
Early and Periodic
Preventive health care services include:
Screening, Diagnosis and • Health screens
• Physical exams
Treatment/Well Child
• Vaccines
Services (EPSDT)
• Lab tests, including blood lead level
• Teaching you about health topics
• Hearing tests
• Dental and vision screenings
LIMITS/
EXCLUSIONS
COPAYMENT
Well-Care visits
end on the month
of the child’s 21st
birthday.
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SERVICES
Health Care Screenings
for Adults
COVERAGE
•
•
•
•
Mammography screening
Prostate cancer screening
Cholesterol screening
Influenza, pneumococcal and hepatitis
vaccines
• Cervical cancer screenings
• Chlamydia screening
• Prenatal visits
Alcohol, Drug, and
Covered.
Substance Abuse Services Alcohol, drug, and substance abuse
treatment services are provided by the
Department of Alcohol and Other Drug
Abuse Services (DAODAS).
LIMITS/
EXCLUSIONS
COPAYMENT
Copayments
Some services will require you to pay a small copayment. Those services and copayments are as follows:
COPAYMENT
$3.40 per visit/per durable medical
equipment or supply
$3.40 per visit
$25.00 per admission
SERVICE
• Durable Medical Equipment and Supplies
• Dental
• Pharmacy (per prescription /refill) - Copay will apply to ages
19 and above only
• *NOTE: Durable Medical Equipment that is under a rent to
purchase payment plan will have the $3.40 co-pay split evenly
among the 10-month rental payment schedule
• Outpatient Hospital (non-emergency)
• Inpatient Hospital
The most up-to-date copay information can be found at molinahealthcare.com. You may also call Member
Services for copay information at 1-855-882-3901 (Hearing Relay Service 711).
Molina Extra Benefits
SERVICES
Newborn Circumcision
Unlimited Office Visits for Adults
Vision (Adult)
Podiatry – Routine Foot Care
No Copayment for Provider Office
Visits, Durable Medical Equipment
(DME), Ambulatory Surgery Centers
and Home Health
LIMITATIONS
Covered for infants up to six (6) months of age
Covered for Members ages 21 and older
Yearly routine eye exam; one (1) lenses and frames every two (2)
years for Members ages 21 and older
Covered for certain medical conditions such as diabetes
Does not include hospital outpatient clinics
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Services Outside the Core Benefits
If you have any questions regarding services outside the core benefits, please call Member Services at
1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711). These services are covered by Medicaid Fee-ForServices (SCDHHS Medicaid plan).
SERVICE
Mental Health Services
Medical (Non-Ambulance)
Transportation
Dental Services
COVERAGE
Mental Health Services are covered by the South Carolina
Department of Health & Human Services (SCDHHS) only
when authorized or provided by a state agency.
Molina Healthcare of South Carolina will help you with
coordinating any necessary mental health services authorized
by SCDHHS.
Medical non-ambulance transportation, defined as
transportation of the Member to or from a Medicaid
covered service, is provided to Members who cannot obtain
transportation on their own or through family, friends or
community resources. Transportation will be available through
the Provider Logisticare.
Beginning July 1, 2014 SCDHHS will allow Medicaid enrolled
dentists to be reimbursed by the Healthy Connections Fee-forService program for services that include cleanings, fillings and
extractions for adults ages 21 and over.
Members under age 21 – routine and emergency dental services
are covered and available through dental Provider DentaQuest.
Targeted Case Management Services (TCM). TCM services are
Certain Behavioral Health Service
offered to:
• These services will assist Members
in gaining access to needed medical,
• Alcohol and substance abuse individuals
social, educational, and other services. • Children in foster care
• Chronically mentally ill adults
• Emotionally disturbed children
• Children in the juvenile justice system
• Sensory impaired individuals
• Individuals with mental retardation or a related disability
• Individuals with a head or spinal cord injury or a related
disability
• Adults in need of protective services
• Intensive family treatment services
• Therapeutic day services for children
• Out-of-home therapeutic placement services for children
• Inpatient psychiatric hospital and residential treatment
facility services
These services are for at-risk youth for pregnancy prevention
Family Planning Prevention Services education and counseling.
Family Planning Prevention Services
from the Medicaid Adolescent Pregnancy
Prevention Services (MAPPS)
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SERVICE
Home and Community-Based
Waiver Services
COVERAGE
Home and community-based waiver services are offered to
Members with long-term care needs. Members will be given
access to services that enable them to remain at home rather
than in an institutional setting.
Your health care plan covers all medically necessary Medicaid-covered services. The services covered by
your health care plan are covered monthly at no cost to you. Your health coverage is subject to change and
modification by government regulatory agencies. Molina Healthcare of South Carolina will notify you of any
changes as they occur. You may refer to Molina’s website at www.MolinaHealthcare.com for the most current
benefit information.
Prior Approval
You can get emergency care and most services without any prior approval. But some services do require prior
approval. For a prior approval request, a Provider must call your health care plan about the care they would like
you to receive. We will review the request based on medical necessity and let your Provider know if the request
is approved before they can give you the service. We will notify your Provider of our decision within 14 calendar
days from receipt of the request for service. However, if it is determined the standard timeframe could be a
risk to your health, we will make a quicker decision and provide notice within 3 calendar days of receipt of the
request for service. You can request up to 14 extra calendar days if you or your Provider need to submit more
information before we make a decision. Molina Healthcare of South Carolina or your Provider can also request
extra days if more information is needed to make a decision. For standard decisions we can request up to 14
extra calendar days and if a quicker decision is needed we can request up to 48 extra hours. We will notify you in
writing if an extension is needed. This is done to ensure that you get appropriate care.
If you have questions about a prior approval request, call Member Services. Prior approval staff can help you
between 8:00 a.m. and 6:00 p.m. Monday through Friday. After business hours, you can leave a message and
someone will call you back the next business day.
There are other times when your PCP may give you a referral. A referral is a request from a PCP asking for his
or her patient to see a specialist. A specialist is a Provider who focuses on a particular kind of health care. We
encourage you to see your PCP for referrals so that your care can be coordinated.
Because your PCP is the person who will submit prior approval requests for you and will send you to specialists
when necessary, it is important that you develop a good relationship with him or her. A good relationship helps
to make sure that your PCP can give you the best care for your needs.
Managed Care Enrollment of Newborns
A newborn baby will be automatically added to the health plan that his or her mother is in at the time of birth.
The baby will be in that same plan for the first 90 days from birth. If you do not wish to have your baby enrolled
in your health plan, you need to call the Medicaid enrollment counselors at SC Healthy Connections Choices at
1-877-552-4642 (TTY: 1.877.552.4670) before the baby is born.
• Newborns that are not linked to a Medicaid mother will stay in fee-for-service Medicaid, or be enrolled
into a health plan by the newborn’s guardian. Newborns that become eligible within the first three (3)
months of life will be added to the mother’s health plan retroactively (after the fact).
• Newborns that are linked to a Medicaid mother who become Medicaid eligible after the first three (3)
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months of life cannot be added to the mother’s health plan retroactively (after the fact). These newborns
may be added in the next available assignment period.
Getting Prescriptions
How to Obtain a Prescription Drug
You can go to any pharmacy that is listed in your Provider Directory. Show your Molina Healthcare of South
Carolina ID card to the pharmacist. All prescriptions that are on your health care plan’s Preferred Drug List will
be covered when medically necessary. Some medications require prior approval from Molina.
You can get a list of participating pharmacies or information about your health care plan’s Preferred Drug
List by contacting Member Services at 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711) or visit our
website at www.MolinaHealthcare.com. Please note our Preferred Drug List and list of medications that require
prior approval can change so it is important for you and/or your doctor to check this information when you need
to fill or refill a medication.
What is Covered?
Prescription drugs that are medically necessary are covered through Molina Healthcare of South Carolina.
Under certain circumstances, the four (4) prescription limit may not apply. There is a Member copay of $3.40 for
prescriptions for Members who are ages 19 and older and not pregnant. Also, if you plan to travel out of state, be
sure to fill your prescriptions before you leave.
For additional information about the pharmacy benefit, a list of preferred drugs, and limitations, please contact
Member Services. A list of in-network pharmacies is available on the www.MolinaHealthcare.com website or by
contacting Molina Healthcare of South Carolina’s Member Service Department at 1-855-882-3901.
Injectable and Infusion Services
Many self-administered and office-administered injectable products require prior approval. In some cases they
will be made available through Molina Healthcare of South Carolina’s vendor, Caremark Specialty Pharmacy. Family planning services related to the injection or insertion of a contraceptive drug or device are covered.
Prior Approval
Some medications listed on the Preferred Drug List need prior approval. This means they must be approved
before you can get them. Reasons why a medication may need prior approval include:
• There is a generic or pharmacy alternative drug available;
• The drug can be misused or abused; or
• There are other drugs that must be tried first.
When a medication requires prior approval, your doctor will need to fax a request to our Pharmacy Department
at 1-855-571-3011. Our Pharmacy Department will review the information provided by the doctor. If the
drug that you are being prescribed needs a prior approval and your doctor does not contact our Pharmacy
Department to request this, you will not be able to get your medication. Your local pharmacist will then notify
the doctor to contact our Pharmacy Department.
If you change health plans, we will honor existing prescriptions requiring a prior approval under our Preferred
Drug List for a period of no less than 30 days.
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Network pharmacies will be able to fill an emergency one-time five (5) day supply in situations where medication
is needed but prior approval has not been given yet. Some drugs may also have quantity (amount) limits. Some
drugs are never covered, such as drugs for weight loss, erectile dysfunction and infertility.
Step Therapy
Some medications listed on the Preferred Drug List require specific medications to be used first before you
can receive the Step Therapy medication. The Step Therapy medications are covered if there is a record that
the required medication has been tried first. If there is no record that the required medication has been tried,
your doctor will need to submit a prior approval request. We will ask your doctor to submit information to us
explaining why you cannot use the required medication first.
Medications Not on Your Health Plan’s Preferred Drug List
If your prescription is not on the Preferred Drug List, the doctor needs to send a prior approval request. If your
doctor does not do this, you will not be able to get your medication. If the doctor chooses not to change your
prescription to a drug on the Preferred Drug List, your doctor will need to submit a prior approval request to the
Pharmacy Department. If the medical exception is denied, you may file an appeal with the plan or file a State Fair
Hearing request with SCDHHS. You may be eligible for a one-time 5-day supply until your doctor can call your
health care plan. Please have your local pharmacy call Member Services at 1-855-882-3901.
The Molina Preferred Drug List can be found online at http://www.molinahealthcare.com/Providers/sc/
medicaid/drug/Pages/pdl.aspx.
Continuation of Medications
If you have been taking a medication that is not on the Molina Preferred Drug List prior to becoming a Member,
you may be eligible to receive a 30-day supply. This will give your doctor time to change your medication to one
that is on our Preferred Drug List or submit a prior approval request.
If you are new to Molina, we will provide a continuation of pharmaceutical services and/or honor the prior
approval for an additional 30 days, for a total of up to 60 days, or until your Membership can be transferred
without disruption when the medication is used to treat one of the following conditions:
• Major Depression
• Schizophrenia
• Bipolar Disorder
• Major Anxiety Disorder
• Attention Deficit/Hyper Activity Disorder (ADD/ADHD)
Brand Name Drugs Instead Of Generic Forms of the Same Drug
We require that generic medications be given to you when they are available. Generic medications have the same
active ingredients as brand name medications. Generic medications are proven as safe and effective as brand
name medications. If your doctor thinks you need a brand name medication instead of the generic form, we will
ask your doctor to submit a prior approval request. We will ask for information to explain why you cannot use
the generic medication. You have the right to file a grievance or appeal with your health care plan or file a State
Fair Hearing request with SCDHHS regarding pharmacy decisions.
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My doctor prescribed a medication for me, but I’m feeling better. Should I keep
taking this medication?”
Molina Healthcare’s registered nurses are available 24 hours a day, 7 days a week to answer
your questions about your medications. Call Molina Healthcare’s 24-Hour Nurse Advice Line at
(888) 275-8750 or (866) 648-3537 (Español), when you have questions about medications for you
or your children. For hearing impaired, call TTY/TTD 711. Molina Healthcare of South Carolina is
committed to getting you the help you need.
Additional Benefits
Non-Discrimination of Caregivers
You must not discriminate against your caregivers because of race, color, national origin, religion, sex, ancestry,
marital status, physical or mental disability, unfavorable military discharge, or age. To do so is a Federal offense.
Transportation Services
All transportation services provided via ambulance are covered. These trips may be routine or non-routine transports
to a Medicaid covered service. We will provide stretcher trips, as well as, air ambulance or Medivac transportation.
Medical non-ambulance transportation is provided to eligible Members who cannot obtain transportation on
their own or through other means such as family, friends, or community resources. Member Services can assist in
arranging your transportation. You can also call the state-approved transportation broker at the below listed phone
number (based on the county you live in) to arrange for transportation if you are qualified for these services.
Transportation Provider:
Logisticare
If you live in one of these counties
please call: 1-866-910-7688
Transportation Provider:
Logisticare
If you live in one of these counties
call: 1-866-445-6860
Transportation Provider:
Logisticare
If you live in one of these
counties call:1-866-445-9954
Abbeville
Anderson
Cherokee
Edgefield
Greenville
Greenwood
Laurens
McCormick
Oconee
Pickens
Saluda
Spartanburg
Aiken
Allendale
Bamberg
Barnwell
Calhoun
Chester
Clarendon
Fairfield
Kershaw
Lancaster
Lee
Lexington
Newberry
Orangeburg
Richland
Sumter
Union
York
Beaufort
Berkeley
Charleston
Chesterfield
Colleton
Darlington
Dillon
Dorchester
Florence
Georgetown
Hampton
Horry
Jasper
Marion
Marlboro
Williamsburg
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Back Transfers
Under certain circumstances, we will coordinate your transfer from one hospital to another hospital, or from a
hospital to a lower level of care, when requested by your Provider. The decision on when and to what levels of
care you are to be transferred should only be made by the attending physician.
We will cover the costs of transfer that are within your benefits and use the transport services agreed to by
the state.
Transportation for Out-of-State Medical Services
You are eligible for pre-approved transportation as described below:
If Molina Healthcare of South Carolina approves out-of-state services and the referral service is available in
state, we will be responsible for all Medicaid covered services related to the referral, including all modes of
transportation, escorts, meals, and lodging.
Also, if we approve out-of-state services and the service is not available in state, we will be responsible for the
cost of referral services and any ambulance or air transportation.
Case Management
Your health care plan has a Case Management Program to assist you with managing your health care. The
professionals who work in the Case Management Program are called case managers.
All case managers are nurses or social workers, and they are part of a team made up of other health care
professionals and support staff.
Your health care plan offers case management services that are available to children and adults with special
health care needs.
Our Case Management Department also offers disease management services which are helpful if you have
trouble controlling a medical condition that requires extra attention, such as:
• Asthma
• Coronary Artery Disease (CAD)
• Behavioral health disorders like depression
• Diabetes
• Chemical dependency
• High blood pressure
• Chronic Obstructive Pulmonary Disease (COPD)
• High-risk pregnancy
• Congestive Heart Failure (CHF)
Case Management can also help you if you have conditions that make your health care complicated.
You can be enrolled in Case Management in a number of ways:
• You can call the Member Services Department if you think that the program would benefit you.
• If your Provider thinks that Case Management would be beneficial to you, he or she may call your health
care plan and request that a case manager call you.
• If a case manager thinks that these services might be helpful to you, he or she will give you a call.
• In order to help you, your health plan will need to learn more about you. A Member of your case
management team will call to ask you questions about your health and lifestyle to determine if case
management can assist you with your medical condition.
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Once you are enrolled in case management, a case manager will work with you face-to-face or by telephone to
learn about your condition and help you to identify the steps to take to get quality health care. Several times a
year, a Member of your case management team will be in contact with you. The purpose of this program is to
help you meet your health care goals. Your case manager will work directly with your PCP and other Providers
to help coordinate your care and will give you information on local resources that may be able to provide you
with additional assistance.
For more information, please call Member Services at 1-855-882-3901 (Hard-of-Hearing TTY Relay Service
711). A representative will be able to connect you with a case manager.
Let your health care plan and your county caseworker know if you learn that you are pregnant so that you get all
of the health information and support that you will need during your pregnancy.
Well Child Program
Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Well Child doctor visits are for all Members
from birth through the month of their 21st birthday. These checkups make sure your children are growing and
getting the health care they need. These checkups include a health, vision, dental, and hearing exam. Children
also get immunizations (shots) and any lab tests needed. Parents and older children will receive health education.
All EPSDT visits and procedures are covered. For information, call Member Services at 1-855-822-3901
(Hard-of-Hearing TTY Relay Service 711).
Women, Infants and Children Program (WIC)
WIC is a special supplemental nutrition program for women and children. The WIC program provides
nutritious food at no cost, breast-feeding support, nutrition education, and health care referrals. If you are
pregnant, ask your doctor to complete a WIC application at your doctor’s appointment. If you have an infant or
child, ask your doctor to complete a WIC application or call the WIC Care Line at 1-800-868-0404, your local
health department, or Member Services Department at 1-855-882-3901.
Motherhood Matters® Pregnancy Program
Molina Healthcare has a special program for pregnant women. This program will help women get the education
and services needed for a healthy pregnancy.
Depending on your needs, the following services may be provided:
• Counseling over the telephone.
• Educational workbooks and other resources.
• Coordination with social services.
• Case management services by a nurse.
If you are pregnant:
• See your provider when you first find out that you are having a baby.
• Do not miss any of your provider visits for prenatal care.
• The provider visits will help you to know how your baby is growing. They can help you get ready for your
baby to be born.
• Your provider will be able to watch any problems that come up while your baby is growing. We want you to
have a healthy pregnancy and a healthy baby.
As part of the program, you will also learn ways to stay healthy after your pregnancy.
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How do members enroll?
Please call our Health Management Department at (866) 891-2320 (TTY/TDD: 7-1-1). Our staff can give you
more information. You can also ask for a referral or to sign up for a program.
How Molina Healthcare of South Carolina Pays for Your Care
Your health care plan contracts with Providers in several different ways. Contracted Providers are paid on a
fee-for-service basis. This means that they are paid each time they see you or for each procedure they perform.
There are also some Providers who are paid a flat amount for each month that a Member is assigned to their care,
whether the Member sees the Provider or not.
Some Providers may offer incentives for preventive care and for monitoring the use of hospital services. Your
health care plan does not reward Providers or employees for denying medical coverage or services. We do not
provide financial incentives for utilization management decisions that could result in denials or underutilization.
Utilization Management decision-making is based only on appropriateness of care and service and existence of
coverage. You can contact your health care plan to get any other information you want, including the structure
and operation and how we pay our Providers.
Your health care plan provides services to Members because of a contract that Molina Healthcare of South
Carolina has with the South Carolina Department of Health and Human Services (SCDHHS). If you want to
contact SCDHHS, you can call or write to:
South Carolina Department of Health and Human Services (SCDHHS)
P.O. Box 8206
Columbia, SC 29202
1-888-549-0820
You can also visit SCDHHS on the web at www.scdhhs.gov.
If you want to tell us about things you think we should change, please call Member Services at 1-855-882-3901
(Hard-of-Hearing TTY Relay Service 711).
What If I Get a Bill?
If you receive a statement from a Provider, check to see if there is any patient responsibility (copayment) listed.
If the letter shows that you are responsible for a copayment, you may be responsible for paying the copayment
if it was not paid at the time of service. If the letter shows that you are responsible for charges in addition to
a copayment or if a Provider asks you to sign an agreement to pay for services, call Member Services right
away. We will help resolve this issue so that you do not receive any bills from the Provider unless you chose to
and have agreed to receive and pay for a service out of your pocket that is NOT a covered Medicaid service.
If the statement does not indicate any patient responsibility, this means you received a statement. You have
not received a bill. The Provider is just notifying you that your insurance company has been billed for the
services provided. These statements note at the top of the page that “this is not a bill,” and you may disregard
the statement. The Provider is not billing you for the services. If you did not receive the services listed in the
statement, please call and report the issue to Member Services at 1-855-882-3901(Hard-of-Hearing TTY Relay
Services 711) right away.
Evaluating New Technology
Your health care plan uses a medical evaluation process to assess whether a new medical device, medical, surgical
or behavioral health protocol/procedure, or other therapy is proven to be safe and effective for a particular
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clinical indication or condition when compared to alternative therapies. The goals of this process are:
• To review and update coverage decisions as new scientific evidence becomes available
• To review individual cases to evaluate whether or not to cover a specifically requested service
If your health care plan denies coverage for a device, a protocol, a procedure, or other therapy that is a new
technology that is not a medically necessary Medicaid-covered service, you or your Provider can ask for
information on coverage protocols and procedures. For more information about our internal assessment process,
please call 1-855-882-3901 (Hard-of-Hearing TTY Relay Service 711).
Your Membership Rights
Each Medicaid MCO Member is guaranteed the following rights:
1. To receive information about your Member rights and responsibilities;
2. To make recommendations to Molina Healthcare about these Member rights and responsibilities;
3. To be treated with respect and with due consideration for your dignity and privacy;
4. To participate in decisions regarding your healthcare, including the right to refuse treatment;
5. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation, as specified in the federal regulations on the use of restraints and seclusion;
6. To be able to request and receive a copy of your medical records, and request that they be amended or
corrected;
7. To receive healthcare services that are accessible, are comparable in amount, duration, and scope to those
provided under Medicaid FFS, and are sufficient in amount, duration, and scope to reasonably be expected
to achieve the purpose for which the services are furnished;
8. To have a candid discussion of appropriate or medically necessary treatment options for your condition
regardless of cost or benefit coverage;
9. To receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of
illness, or medical condition;
10.To receive all information, including, but not limited to, enrollment notices, informational materials,
instructional materials, available treatment options, and alternatives in a manner and format that may be
easily understood;
11.To receive assistance from both SCDHHS and Molina Healthcare of South Carolina in understanding the
requirements and benefits of the Molina Healthcare of South Carolina’s plan;
12.To receive oral interpretation services free of charge for all non-English languages, not just those identified
as prevalent;
13.To be notified that oral interpretation is available and how to access those services;
14.As a potential Member, to receive information about the basic features of managed care, which populations
may or may not enroll in the program and the MCO’s responsibilities for coordination of care in a timely
manner in order to make an informed choice;
15.To receive information on Molina Healthcare of South Carolina’s services, to include, but not limited to:
a. Benefits covered;
b. Cost-sharing requirements;
c. Procedures for obtaining benefits, including any authorization requirements;
d. Service area
e. Names, locations, telephone numbers of non-English language spoken by current contracted Providers,
including at a minimum, primary care physicians, specialists, and hospitals;
f. Any restrictions on Member’s freedom of choice among network Providers;
g. Providers not accepting new patients; and
h. Benefits not offered by Molina Healthcare of South Carolina but available to Members and how to
obtain those benefits, including how transportation is provided.
16.To receive a complete description of disenrollment rights at least annually;
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17.To receive notice of any significant changes in the Benefits Package at least thirty (30) days before the
intended effective date of the change;
18.To receive information on the Appeal, Grievance, and State Fair Hearing procedures including the right to
file;
19.To be able to file an appeal, a grievance (complaint) or request a State Fair Hearing;
20.To receive detailed information on emergency and after-hours coverage, to include, but not limited to:
a. What constitutes an emergency medical condition, emergency services, and post-stabilization services;
b. Emergency services do not require prior approval;
c. The process and procedures for obtaining emergency services;
d. The locations of any emergency settings and other locations at which Providers and hospitals provide;
e. Emergency services and post-stabilization services covered under the contract. Your right to use any
hospital or other setting for emergency care; and f. Post-stabilization care services.
21.To receive Molina Healthcare of South Carolina’s policy on referrals for specialty care and other benefits
not provided by your Primary Care Provider;
22.To have your privacy protected in accordance with the privacy requirements in the Code of Federal
Regulations (45 CFR, 160, 164 (A)(E)), to the extent that they are applicable; and
23.To exercise these rights without adversely affecting the way Molina Healthcare of South Carolina, its
Providers, or SCDHHS treats the Members;
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Your Membership Responsibilities
As a Member of Molina Healthcare, you have the responsibility to:
• To provide information to your doctor that is needed to make decisions about your health care;
• To be active in decisions about your health care;
• To follow the care plans and instructions that you have agreed upon with your doctor(s);
• To build and keep a strong patient-doctor relationship, you have the responsibility to cooperate with your
doctor and staff. This includes being on time for your visits or calling your doctor if you need to cancel or
reschedule an appointment;
• To present your Molina Healthcare ID card and state ID card when receiving medical care;
• To report any fraud or wrongdoing to Molina Healthcare of South Carolina or the proper authorities;
• To understand your health problems and participate in developing mutually agreed-upon treatment goals;
• To inform Molina Healthcare of South Carolina Member Services Department of any change of address or
any changes to entitlement that could affect continuing eligibility;
• To inform Molina Healthcare of South Carolina of the loss or theft of your Member ID card(s);
• To be familiar with Molina Healthcare of South Carolina’s procedures to the best of your ability;
• To contact Molina Healthcare of South Carolina if you need information or have any questions about
your care;
• To access and use preventive care services
• Non-Discrimination of Caregivers - you must not discriminate against your caregivers because of race,
color, national origin, religion, sex, ancestry, marital status, physical or mental disability, unfavorable
military discharge, or age. To do so is a Federal offense; and
• To keep your health plan, you must renew your coverage every year to keep your SC Healthy Connections
coverage. You will receive a redetermination packet from the South Carolina Department of Health and
Human Services (SCDHHS) at least 60 days before your coverage ends. If you do not receive your packet,
call your SCDHHS case manager. Molina Members, if you have questions, call Molina at (855) 882-3901 or
call Healthy Connections at (888) 549-0820 to help renew your benefits.
Your Privacy
Your privacy is important to us. We respect and protect your privacy. Molina uses and shares your information
to provide you with health benefits. We want to let you know how your information is used or shared.
Your Protected Health Information (PHI)
PHI means protected health information. PHI includes your name, Member ID number or other identifiers, and
is used or shared by Molina.
Why Does Molina Use or Share Our Member’s PHI?
•
•
•
•
•
•
To provide for your health care treatment;
To pay for your health care;
To review the quality of the care you get;
To tell you about your choices for care;
To operate our health plan; and
To use your PHI for other purposes as required or permitted by law.
When Does Molina Need Your Written Authorization (approval) to Use or Share Your PHI?
Molina needs your written approval to use or share your PHI for purposes not listed above.
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What Are Your Privacy Rights?
•
•
•
•
•
To look at your PHI;
To get a copy of your PHI;
To amend your PHI;
To ask us not to use or share your PHI in certain ways; and
To get a list of certain people or places we have given your PHI.
How Does Molina Protect Your PHI?
Molina uses many ways to protect PHI across our health plan. This includes PHI in written word, spoken word,
or in a computer. Below are some ways Molina protects PHI:
• Molina has policies and rules to protect PHI.
• Molina limits who may see PHI. Only Molina staff with a need to know PHI may use it.
• Molina staff is trained on how to protect and secure PHI.
• Molina staff must agree in writing to follow the rules and policies that protect and secure PHI.
• Molina secures PHI in our computers. PHI in our computers is kept private by using firewalls
and passwords.
What Must Molina Do By Law?
• Keep your PHI private;
• Give you written information such as this on our duties and privacy practices about your PHI; and
• Follow the terms of our Notice of Privacy Practices.
What Can You Do if You Feel Your Privacy Rights Have Not Been Protected?
• Call or write Molina to report your suspicions; and
• Call or write to SCDHHS to report your suspicisions.
We will not hold anything against you. Your action would not change your care in any way.
The above is only a summary. Our Notice of Privacy Practices has more information about how we use and
share our Members’ PHI. Our Notice of Privacy Practices is in the following section of this document. It is
on our web site at www.molinahealthcare.com. You may also get a copy of our Notice of Privacy Practices by
calling our Member Services Department at 1-855-882-3901.
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Notice of Privacy Practices
MOLINA HEALTHCARE OF SOUTH CAROLINA, LLC.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
Molina Healthcare of South Carolina (“Molina Healthcare”, “Molina”, “we” or “our”) uses and shares protected
health information about you to provide your health benefits. We use and share your information to carry out
treatment, payment, and health care operations. We also use and share your information for other reasons as
allowed and required by law. We have the duty to keep your health information private and follow the terms of
this Notice. The effective date of this notice is Dec 1, 2013.
PHI stands for these words: protected health information. PHI means health information that includes your
name, Member number or other identifiers, and is used or shared by Molina.
Why does Molina use or share your PHI?
We use or share your PHI to provide you with health care benefits. Your PHI is used or shared for treatment,
payment, and health care operations.
For Treatment
Molina may use or share your PHI to give you or arrange for your medical care. This treatment also includes
referrals between your Providers or other health care Providers. For example, we may share information about
your health condition with a specialist. This helps the specialist talk about your treatment with your Provider.
For Payment
Molina may use or share PHI to make decisions on payment. This may include claims, approvals for treatment,
and decisions about medical needs. Your name, your condition, your treatment, and supplies given may be
written on the bill. For example, we may let a doctor know that you have our benefits. We would also tell the
doctor the amount of the bill that we would pay.
For Health Care Operations
Molina may use or share PHI about you to run our health plan. For example, we may use information from your
claim to let you know about a health program that could help you. We may also use or share your PHI to solve
Member concerns. Your PHI may also be used to see that claims are paid right. Health care operations involve
many daily business needs. It includes, but is not limited to, the following:
•
•
•
•
•
•
Improving quality;
Actions in health programs to help Members with certain conditions (such as asthma);
Conducting or arranging for medical review;
Legal services, including fraud and abuse programs;
Actions to help us obey the law; and
Address Member needs, including solving complaints and grievances.
We will share your PHI with other companies (“business associates”) that perform different kinds of activities for
our health plan. We may also use your PHI to give you reminders about your appointments. We may use your
PHI to give you information about other treatments, or other health-related benefits and services.
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When can Molina use or share your PHI without getting written authorization (approval)
from you?
The law allows or requires Molina to use and share your PHI for several other purposes including the following:
Required by law
We will use or share information about you as required by law. We will share your PHI when required by
Secretary of the Department of Health and Human Services (HHS). This may be for a court case, other legal
review, or when required for law enforcement purposes.
Public Health
Your PHI may be used or shared for public health activities. This may include helping public health agencies to
prevent or control disease.
Health Care Oversight
Your PHI may be used or shared with government agencies. They may need your PHI for audits.
Research
Your PHI may be used or shared for research in certain cases.
Legal or Administrative Proceedings
Your PHI may be used or shared for legal proceedings, such as in response to a court order.
Law Enforcement
Your PHI may be used or shared with police to help find a suspect, witness or missing person.
Health and Safety
Your PHI may be shared to prevent a serious threat to public health or safety.
Government Functions
Your PHI may be shared with the government for special functions. An example would be to protect
the President.
Victims of Abuse, Neglect or Domestic Violence
Your PHI may be shared with legal authorities if we believe that a person is a victim of abuse or neglect.
Workers Compensation
Your PHI may be used or shared to obey Workers Compensation laws.
Other Disclosures
Your PHI may be shared with funeral directors or coroners to help them do their jobs.
When does Molina need your written authorization (approval) to use or share your PHI?
Molina needs your written approval to use or share your PHI for a purpose other than those listed in this Notice.
Molina needs your authorization before we disclose your PHI for the following: (1) most uses and disclosures of
psychotherapy notes; (2) uses and disclosures for marketing purposes; and (3) uses and disclosures that involve
the sale of PHI. You may cancel a written approval that you have given us. Your cancellation will not apply to
actions already taken by us because of the approval you already gave to us.
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What are your health information rights?
You Have The Right To:
Request Restrictions on PHI Uses or Disclosures (Sharing of Your PHI)
You may ask us not to share your PHI to carry out treatment, payment, or health care operations. You may also
ask us not to share your PHI with family, friends, or other persons you name who are involved in your health
care. However, we are not required to agree to your request. You will need to make your request in writing. You
may contact Member Services to request Molina’s form for your use.
Request Confidential Communications of PHI
You may ask Molina to give you your PHI in a certain way or at a certain place to help keep your PHI private.
We will follow reasonable requests, if you tell us how sharing all or a part of that PHI could put your life at risk.
You will need to make your request in writing. You may contact Member Services to request Molina’s form for
your use.
Review and Copy Your PHI
You have a right to review and get a copy of your PHI held by us. This may include records used in making
coverage, claims, and other decisions as a Molina Member. You will need to make your request in writing. You
may contact Member Services to request Molina’s form for your use. We may charge you a reasonable fee for
copying and mailing the records. In certain cases we may deny the request.
Important Note: We do not have complete copies of your medical records. If you want to look at, get a copy of, or
change your medical records, please contact your doctor or clinic.
Amend Your PHI
You may ask that we amend (change) your PHI. This involves only those records kept by us about you as a
Member. You will need to make your request in writing. You may request Molina’s form for your use. You may
file a letter disagreeing with us if we deny the request.
Receive an Accounting of PHI Disclosures (Sharing of your PHI)
You may ask that we give you a list of certain parties that we shared your PHI with during the six years prior to
the date of your request. The list will not include PHI shared as follows:
• for treatment, payment, or health care operations;
• to persons about their own PHI;
• sharing done with your authorization;
• incident to a use or disclosure otherwise permitted or required under applicable law;
• PHI released in the interest of national security or for intelligence purposes; and
• As part of a limited data set in accordance with applicable law.
We will charge a reasonable fee for each list if you ask for this list more than once in a 12-month period. You will
need to make your request in writing. You may use Molina’s form to make your request.
You may make any of the requests listed above, or may get a paper copy of this Notice. Please call our Member
Services Department at 1-(855) 882-3901.
What can you do if your rights have not been protected?
You may complain to Molina and to the Department of Health and Human Services if you believe your privacy
rights have been violated. We will not do anything against you for filing a complaint. Your care and benefits will
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not change in any way.
You may file a complaint with us at:
Molina Healthcare of South Carolina
Attention: Manager of Member Services
P.O. Box 40309
North Charleston, SC 29423-0309
(855) 882-3901
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services at:
Office of Civil Rights
U.S. Department of Health & Human Services
Sam Nunn Atlanta Federal Center, Suite 16T70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
Voice Phone (800) 368-1019; TDD (800) 537-7697;
FAX (404) 562-7881
What are the duties of Molina?
Molina is required to:
• Keep your PHI private;
• Give you written information such as this on our duties and privacy practices about your PHI;
• Provide you with a notice in the event of any breach of your unsecured PHI;
• Not use or disclose your genetic information for underwriting purposes; and
• Follow the terms of this Notice.
This Notice is Subject to Change
Molina reserves the right to change its information practices and terms of this Notice at any time. If we do,
the new terms and practices will then apply to all PHI we keep. If we make any material changes, Molina
will post the revised Notice on our web site and send the revised Notice, or information about the material
change and how to obtain the revised Noticed, in our next annual mailing to our Members then covered
by Molina.
Contact Information
If you have any questions, please contact the following office:
Attention: Manager of Member Services
Molina Healthcare of South Carolina
P.O. Box 40309
North Charleston, SC 29423-0309
Important Information about Your Medicaid Eligibility and Coverage Loss of Medicaid Eligibility
It is important that you keep your appointments with the County office of the South Carolina Department of
Health and Human Services. If you miss a visit or do not give them the information they ask for to certify you
for Medicaid coverage, you can lose your Medicaid eligibility. If this would happen, Molina Healthcare of South
Carolina would be told to stop your Membership as a Molina Member and you would no longer be covered by
Medicaid through us.
Loss of Insurance Notice (Certificate of Creditable Coverage)
Any time you lose health insurance you should receive a notice, known as a certificate of creditable coverage,
from your old insurance company that says you no longer have insurance. It is important that you keep a copy of
this notice for your records because you might be asked to provide a copy.
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You should also notify us if you get another health insurance policy, including employer-sponsored insurance.
Automatic Renewal of MCO Membership
If you lose your Medicaid eligibility but it is started again within 60 days, you will automatically become a Molina
Healthcare of South Carolina Member again.
Accidental Injury or Illness (Subrogation)
If a Molina Healthcare of South Carolina Member has to see a doctor for an injury or illness that was caused
by another person or business, you must call the Member Services Department to let us know. For example, if
you are hurt in a car wreck, if your are a victim of a dog bite, or if you fall and are hurt in a store, then another
insurance company might have to pay the doctor’s and/or hospital’s bill. When you call, we will need the name of
the person at fault, their insurance company and the name(s) of any attorneys involved.
You should also report any Worker’s Compensation claims, a pending personal injury or medical malpractice
law suit.
Appeals and Grievances
A. Enrollee Services and Hotline Information
Member Services is open Monday through Friday, 8:00 am to 6:00 p.m., except on state approved holidays. The
phone number is 1-855-882-3901. We can help you in English or Spanish. An interpreter can be called for other
languages. Call if you have questions about:
•
•
•
•
•
Your health care benefits
Information on doctors
Wellness programs
You have a grievance
Any concerns about your health or health of a family Member
B. Grievance Procedure
A Grievance is defined as an expression of dissatisfaction about any matter other than an action.
An action is any denial that is:
• Limiting or denying services;
• Reducing services;
• Suspending services;
• Terminating services; or
• Denying payment for services.
Examples of grievances include:
• Not being able to find a doctor;
• Trouble getting an appointment; or
• Not being treated fairly by someone who works at Molina or at your doctor’s office.
If you are dissatisfied, you or a person you choose and name, such as an attorney or Provider, may file a formal
complaint or grievance orally by contacting us at 1-855-882-3901. You may also file a complaint in writing. A
grievance may be filed within ninety (90) calendar days of the occurrence. If you need an interpreter to talk to us
in another language, you can ask for one by calling Member Services.
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We will resolve your grievance as quickly as possible, but no later than ninety (90) calendar days from the day
Molina receives your grievance.
The timeframe to resolve a grievance may be extended for another fourteen (14) days if you or your authorized
representative or Molina thinks it would be in the your best interest (for example, additional information is
needed). If an extension is requested, Molina must be able to explain to SCDHHS how the delay is in your best
interest. A letter will be sent to you informing you of the extension and why it is being granted.
If you would like a copy of our official grievance procedure or if you need help filing a grievance, please call
1-855-882-3901 or refer to the end of the Member Handbook for the Member Grievance Request form. If you
are hard of hearing, call our TTY line. It may take some time, please do not hang up.
Appeals
If you do not agree with our decision to deny a requested service(s), and you contact us within ninety (90)
calendar days to ask that we change our decision - this is called an Appeal. You, your authorized representative
(this can be a friend, family Member, attorney) or a Provider may file an Appeal orally or in writing within
ninety (90) calendar days from the date of the Notice of Action (“NOA”) letter you received informing you of the
denial or other action. You can call us to file your Appeal or you may send your Appeal in writing. If you call to
file an oral Appeal, then you must send us a written, signed Appeal within thirty (30) calendar days from the day
you initially filed your Appeal. We also have a simple form in the back of this handbook you can use to file your
Appeal. The written letter must be signed by you or your representative in order for the letter to be approved. Just
call 1-855-882-3901 and we will assist you with filing an Appeal.
When you file an Appeal, be sure to let us know any new information that you have that will help us review
our decision. We will send you a letter letting you know that we received your Appeal within five (5) business
days of receiving your request. While your Appeal is being reviewed, you can still send or deliver any additional
information that you think will help us make our decision.
When reviewing your Appeal, we will:
• Use doctors who know about the type of illness you have;
• Not use the same doctors or medical people who denied your request for a service; and
• Make a decision about your Appeal within 30 calendar days of receipt of your request for a service
We will resolve your standard Appeal as quickly as possible, but no later than thirty (30) calendar days from the
day Molina receives your appeal. The timeframe to resolve your Appeal can be extended another fourteen (14)
calendar days if you or Molina think it would be in your interest (for example, additional information is needed).
If an extension is requested, Molina must be able to explain to SCDHHS how the delay is in your best interest. A
letter will be sent to you informing you of the extension and why it is being granted.
Expedited Appeals
If you or your doctor think that waiting up to thirty (30) calendar days for a standard Appeal is too long and
would be life threatening, could hurt your health or ability to attain, maintain, or regain maximum function,
you may request an expedited Appeal. We will determine if your request meets the expedited Appeal criteria
within twenty-four (24) hours of your Appeal request. If it meets the criteria, we will make a decision as quickly
as possible, but no later than seventy-two (72) hours from the day when we received your request. If you request
an expedited Appeal, you do not have to follow-up with a written request. If it does not meet the criteria for an
expedited Appeal, we will let you know in writing and it will be resolved within the normal thirty (30) days. The
timeframe to resolve your Appeal can be extended another fourteen (14) calendar days if you or Molina think it
would be in your interest (for example, additional information is needed). If an extension is requested, Molina
must be able to explain to SCDHHS how the delay is in your best interest. A letter will be sent to you informing
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you of the extension and why it is being granted. If your Appeal is about a service that was already authorized
and you were already receiving, you may be able to keep getting the service while we review your Appeal.
Contact us at 1-855-882-3901 if you would like to keep getting services while your Appeal is being reviewed.
If your Appeal is denied, you may have to pay for the services that you received while the Appeal was being
reviewed. If at any time during this process, you want to see the Molina case file or see any documents related to
your Appeal, you may request this and Molina will provide these items to you.
Once we complete our review, we will send you a certified letter letting you know our decision. If we decide that
you should not receive the denied service, that letter will tell you how to ask for a State Fair Hearing.
State Fair Hearing
If we review your Appeal request and still deny the services you requested, we will notify you by certified mail
and you will be required to sign a receipt showing that you received the letter. If you are not happy with the
Appeal decision, you have the right to request a State Fair Hearing. You may request a State Fair Hearing within
thirty (30) calendar days of the date you signed for the certified letter telling you our decision. You must exhaust
Molina Healthcare of South Carolina’s internal Appeals process prior to seeking a State Fair Hearing. If your
State Fair Hearing is about a service that was already authorized and you were already receiving, you may be
able to keep getting the service while your Hearing is pending. Contact us at 1-855-882-3901 if you would like to
keep getting services while your Hearing is pending. If the Hearing is not decided in your favor, you may have to
pay for the services that you received while the Hearing is pending.
To request a State Hearing you must submit the request in writing to:
South Carolina Department of Health and Human Services
Division of Appeals and Hearings (Suite 901)
P.O. Box 8206
Columbia, SC 29202-8206
Phone: 1-803-898-2600
Fax: 803-255-8206
www.scdhhs.gov/appeals
Membership Termination
Sometimes there may be a special reason (or cause) that means you need to end your Molina Membership.
Before you ask for a Membership termination, we would like for you to call Molina and give us a chance to
resolve the issue. You can ask for a termination at any time if you have one of the following reasons:
1. You move and Molina is not available where you now live and you must receive non-emergency medical
care in your new area before your Molina Membership ends.
2. Molina does not, for moral or religious objections, cover a medical service that you need.
3. Your doctor has said that some of the medical services you need must be received at the same time, and all
the services are not available in Molina’s Provider network.
4. Poor quality of care, lack of access to medically necessary covered services, or lack of access to Providers
that are experienced in dealing with your special health care needs.
Changing your Managed Care Organization
As a member of a Managed Care Organization, you have the right to change your health plan at certain
times during the year without cause. You can choose to change your Managed Care Organization during the
first ninety (90) calendar days of your enrollment in the health plan or during your yearly managed care reenrollment period. SC Healthy Connections Choices will send you something in the mail to let you know when
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your annual re- enrollment period will be. You will have to choose another Managed Care Organization to
receive your health care.
If you want to change your Managed Care Organization during the first ninety (90) calendar days of your
enrollment in the health plan or during your annual re-enrollment period, you can call SC Healthy Connections
Choices at 1-877-552-4642 (TTY: 711). Most of the time, if you call before the last ten (10) days of the month,
your health plan enrollment will end the first day of the next month. If you call after this time, your membership
will not end until the first day of the following month. If you chose another Managed Care Organization, your
new plan will send you information in the mail within 14 days of the effective date of the health plan change.
Yearly Chance to Choose a New Plan
Once every twelve months, each Member will have a sixty (60) day period in which to change their current Managed
Care Organization. If a Member selects a different Managed Care Organization during the annual re-enrollment
period, enrollment in the new Managed Care Organization will be effective on the enrollee’s anniversary date.
Members who make no selection will continue to be enrolled with the same Managed Care Organization.
If you are thinking about ending your membership with Molina and changing to another health plan, you should
learn about your choices, especially if you want to keep your current doctor. Remember, each health plan has
its own list of doctors and hospitals that it will allow you to use. Each health plan also has written information
which explains the benefits it offers and the rules that it has. If a Member selects a different Managed Care
Organization during the annual re-enrollment period, enrollment in the new MCO will be effective on the
enrollee’s anniversary date. Members who make no selection will continue to be enrolled with the same MCO.
If you would like written information about a health plan, please contact the SC Healthy Connections Choices
at 1-877-552-4642 (TTY: 711). You can also find information about the health plans in your area by visiting
www.scchoices.com.
Can Molina Healthcare of South Carolina End My Membership?
Molina Healthcare of South Carolina may ask the South Carolina Department of Health and Human Services
to end your Membership with Molina for certain reasons. SCDHHS must accept the request before your
Membership can be ended.
The reasons that Molina Healthcare of South Carolina can ask to end your Membership are:
• Loss of Medicaid eligibility or loss of Molina program eligibility (If you become dis-enrolled due to a loss of
Medicaid eligibility, but regain Medicaid eligibility within sixty (60) calendar days, you will be automatically
re- enrolled in Molina’s plan);
• You become deceased;
• You intentionally submit fraudulent information;
• You become an inmate of a public institution;
• You move out of state;
• You elect hospice;
• You become Medicare eligible;
• You become institutionalized in a long-term care facility or nursing home for more than ninety (90)
continuous days;
• You elect home and community based waiver programs;
• You become age 65 or older;
• You enroll in a commercial HMO;
• You are placed out of home (i.e., Intermediate Care Facility for the Mentally Retarded (ICF/MR), Psychiatric
• Residential Treatment Facility (PRTF));
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• Your behavior is disruptive, unruly, abusive, or uncooperative and impairs the MCO’s ability to furnish
services to you or other enrolled Members; or
• If Molina no longer operates as a Managed Care Organization.
Molina may not request disenrollment because of an adverse change in your health status, or due to use of medical
services, diminished mental capacity, or uncooperative or disruptive behavior resulting from special needs.
If You Have Followed Any of the Above Steps to End Your Membership, Remember:
Continue to use Molina Healthcare of South Carolina doctors and other Providers until the day you are a
Member of your new health plan or back on regular Medicaid.
• If you chose a new health plan and have not received a Member ID card before the first day of the month
when you are a Member of the new plan, call the plan’s Member Services Department. If they are unable to
help you, then you must call the South Carolina Department of Health and Human Services at
1-888-549-0820 (Hard-of-Hearing Relay Service 711).
• If you were allowed to return to regular Medicaid and you have not received a new Medicaid card, call your
county caseworker.
• If you have chosen a new health plan and have any medical visits scheduled, please call your new plan to be
sure that these Providers are on the new plan’s list of Providers and any needed paperwork is done. Some
examples of when you should call your new plan include: when you have an appointment to see a new
Provider, a surgery is scheduled, you are scheduled to have blood tests or x-rays - especially if you
are pregnant.
• If you were allowed to return to regular Medicaid and have any medical visits scheduled, please call the
Providers to be sure that they will take the regular Medicaid card.
Fraud and Abuse
Molina Healthcare of South Carolina seeks to uphold the highest ethical standards for the provision of health
care benefits and services to its Members and supports the efforts of federal and state authorities to prevent fraud
and abuse. Molina Healthcare of South Carolina investigates all suspected cases of fraud and abuse and promptly
reports all confirmed incidences to the appropriate government agencies.
Here are a few examples of health care fraud and abuse:
• Your Provider prescribes more services than are necessary, such as:
• Appointments
• Treatments
• Prescriptions
• You are billed for services that you did not receive.
• Another person uses your Member ID card.
• You or someone you know are suspected of selling your prescription drugs.
• You or someone else you know changes the information on a prescription.
You have the right to report your concerns to Molina Healthcare of South Carolina and/or the South Carolina
Department of Health and Human Services. Molina Healthcare AlertLine can be reached toll free at 1-866-606-3889
or you may use the service’s website to make a report at any time at https://molinahealthcare.alertline.com. When
reporting suspected incidences, please leave a detailed message including the names and phone numbers of the parties
involved. You do not have to leave your name if you do not wish to do so.
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Suspected fraud and abuse may also be reported directly to the State at:
South Carolina Department of Health and Human Services Medicaid Fraud and Abuse Hotline
Toll Free Phone: 1-888-364-3224
South Carolina Attorney General Medicaid Fraud Unit
By Phone: 1-803-734-3660 or Toll Free 1-888-662-4328
By Email: [email protected]
Advance Directives
An Advance Directive is a legal document that states your wishes and lets you choose who can make decisions if
you cannot. These are written instructions relating to managing health care when an adult is incapacitated.
These include documents such as a Living Will, a Durable Power of Attorney for Medical Care, a Declaration
for Mental Health Treatment, organ and tissue donation, or a Do Not Resuscitate Order. If you are 18 years
old or older, your Provider must inform you of your right to make health care decisions and execute Advance
Directives. It is important that you are informed about Advance Directives.
Your Provider must honor your Advance Directives to the fullest extent permitted under law. You may select a
new PCP if the assigned Provider has an objection to your desired decision. Molina will facilitate finding you a
new PCP or specialist as needed.
PCPs must discuss Advance Directives with you and provide appropriate medical advice if you desire guidance
or assistance. Molina’s contracted practitioners and facilities are expected to communicate any objections they
may have to your directive prior to service whenever possible. In no event may any Provider refuse to treat you
or otherwise discriminate against you because you have completed an Advance Directive. Federal law gives
you the right to file a grievance with Molina or the State Survey and Certification Agency if you are dissatisfied
with Molina’s handling of Advance Directives and/or if a Provider fails to comply with Advance Directives
instructions.
Advance Directives include your written choice(s) for health care. There are several types of Advance Directives:
• Durable Power of Attorney for Medical Care: Allows an agent to be appointed to carry out health care
decisions in the event you are unable to do so. You can choose any adult relative or friend whom you trust
to act for you when you cannot act for yourself. Be sure you talk with the person about what you want. Then
write down what you do or do not want on your form. You should also talk to your Provider about what you
want. The person you choose must follow your wishes.
• Living Will: Allows choices about withholding or withdrawing life support and accepting or refusing
nutrition and/or hydration. A living will ensures that your wishes regarding life support will be abided by in
the event that you are unable to make your wishes known.
• Guardian Appointment: Allows you to nominate someone to be appointed as your guardian if a court
determines that a guardian is necessary.
• Declaration for Mental Health Treatment: Gives more specific attention to mental health care. It allows you,
while capable, to appoint an agent to make decisions on your behalf when you lack the capacity to make a
decision. In addition, the declaration can give you the right to make certain wishes regarding treatment. The
Declaration for Mental Health Treatment replaces a Durable Power of Attorney for Mental Health Care, but
does not replace a Living Will.
Advance Directives completed prior to the establishment of the current combined form are still valid. Advance
Directives that were executed in another state using another state’s form are also valid.
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When There Is No Advance Directive: Your family and Provider will work together to decide on the best care for
you based on information they may know about your end-of-life plans.
Frequently asked Questions Regarding Advanced Directives:
If I have a Durable Power Of Attorney for medical care, do I need a Living Will too?
You may want both. Each addresses different parts of your medical care. A Living Will makes your wishes known
directly to your Providers, but states only your wishes about the use of life-support methods. A Durable Power of
Attorney for Medical Care allows a person you choose to carry out your wishes for all of your medical care when
you cannot act for yourself. A Durable Power of Attorney for Medical Care does not replace a Living Will.
Can I change my Advance Directive?
Yes, you can change your Advance Directive whenever you want. It is a good idea to look over your Advance
Directives from time to time. Make sure they still say what you want and that they cover all areas.
Where do I get Advance Directive forms?
Many of the people and places that give you medical care have Advance Directive forms. Call Molina Member
Services if you have any questions about how to get this form. A lawyer could also help you.
What do I do with my forms after filling them out?
You should give copies to your Provider and health care facility to put into your medical record. Give one to a
trusted family Member or friend. If you have chosen someone as your Durable Power of Attorney for Medical
Care, give that person a copy. Put a copy with your personal papers. You may want to give one to your lawyer
or clergy. Be sure to tell your family or friends what you have done. Do not just put these forms away and forget
about them.
Glossary/Definitions
Abuse – Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in
unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or
that fail to meet professionally recognized standards for health care. It also includes recipient practices that result
in unnecessary cost to the Medicaid program.
Action – The denial or limited authorization of a requested service including the type or level of service; the
reduction, suspension, or termination of a previously authorized service; the denial, in whole or part, of payment
for a service; or the failure to provide services in a timely manner, as defined by the State.
Advance Directives – Written instructions relating to the provision of health care when an adult is incapacitated,
such as a Living Will, a Durable Power of Attorney for Medical Care, a Declaration for Mental Health Treatment,
or a Do Not Resuscitate Order.
Ancillary Services – Health services ordered by a Provider, including but not limited to laboratory services,
radiology services, and physical therapy.
Appeal – A formal request for Molina Healthcare of South Carolina to review a decision or action.
Authorization – An approval for a service.
Covered Services – Services and supplies covered by Molina Healthcare of South Carolina.
Emergency Medical Condition – A medical problem that you think is so serious that it must be treated right
away by a Provider.
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Emergency Services – Services provided by a qualified Provider, that are needed to evaluate, treat, or stabilize an
emergency medical condition.
Fraud – Intentional deception or misrepresentation by a person with the knowledge that the deception could
result in some unauthorized benefit to themselves or some other person.
Grievance – An oral or written expression of dissatisfaction about any matter other than an “Action”.
Medicaid – The state and federally funded medical program created under Title XIX of the SSA.
Medical Home – To have one Provider who will help you with most of your medical needs.
Medically Necessary Services – Services necessary for the diagnosis or treatment of disease, illness, or injury,
without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of
function, dysfunction of a body organ or part, or significant pain and discomfort.
Member – A person who is eligible for Medicaid and who is enrolled in the Molina Healthcare of South
Carolina plan.
Molina Healthcare of South Carolina – A Managed Care Organization licensed by the State of South Carolina
to provide prepaid medical and hospital services to Medicaid eligible consumers.
Participating/Contracted Provider – A Provider who has entered into a contract with Molina Healthcare of
South Carolina to provide covered services to Members.
Post-Stabilization – Medicaid-covered services that you receive after emergency medical care.
Preventive Health Care – Health care focused on early detection and treatment of health problems and the
prevention of disease or illness.
Primary Care Provider (PCP) - A Molina Healthcare of South Carolina contracted Provider that helps you with
most of your medical needs.
Prior Approval – The process for any service that needs an authorization from Molina Healthcare of South
Carolina before it can take place. A review by Molina Healthcare of South Carolina of the medical necessity and
coverage of planned covered services.
Provider Directory – A list of all of the Providers contracted with Healthcare of South Carolina.
Referral – A request from a PCP for his or her patient to see another Provider for care.
Service Area – The geographic area where Molina Healthcare of South Carolina provides services.
Specialist – A Provider who focuses on a particular kind of health care.
Utilization Management – The evaluation of the appropriateness of health care services.
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Molina Healthcare of South Carolina
Member Grievance Request Form
Instructions for filing a grievance:
1. Fill out this form completely. Describe the issue(s) in as much detail as possible.
2. Attach copies of any records you wish to submit. (Do Not Send Originals).
3. If you have someone else submit on your behalf, you must give your consent below.
4. You may submit the completed form through one of the following ways:
a. Send to the address listed below,
b. Fax to the fax number below, or
c. Present your information in person. To do this, call us at the number listed below.
5. We will send a written acknowledgement letter to you within 5 business days.
Member’s name: Today’s date: Name of person requesting grievance, if other than the Member: Relationship to the Member: Member’s ID #: Daytime telephone #: Email Address: Specific issue(s): (Please state all details relating to your request including names, dates and places. Attach another sheet of paper to this form if more space is needed)
By signing below, you agree that the information provided is true and correct. If someone else is completing this
form for you, you are giving written consent for the person named above to submit on your behalf.
Member’s Signature: Date: If you would like help with your request, we can help. We can help you in the language you speak or if you need
other special support for hearing or seeing. You can call, write, or fax us at:
Member Services Department:
Phone: 1-855-882-3901
Fax: 1-877-823-5961
Attn: MIRR Department
Mail:
Molina Healthcare of South Carolina
Attn: MIRR Department
P.O. Box 40309
North Charleston, SC 29423-0309
Your privacy is important to us. Please know that even though Molina Healthcare of South Carolina has strict
privacy policies and practices, you may be sending this information from a fax that is not secure. Please be aware
of that when sending personal information.
Important Information You Need to Know
If you are unhappy with the steps Molina Healthcare of South Carolina and/or your doctor took for your request, let
us know. You can fill out the enclosed Member Grievance Request Form to file a grievance. You may also call us.
• We will resolve your grievance as quickly as possible, but no later than ninety (90) calendar days from the
date your grievance was received.
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MEDICAL APPEAL REQUEST
If you want to appeal the decision we have made, you can write a letter or fill out this form and send it to us
within 90 calendar days from the date on the Notice of Action for a regular appeal. You can also call us within 90
calendar days from the date on the Notice of Action. If you call us first, you must still send a letter or this form to
us within 30 calendar days after you called us.
If you or your doctor thinks your life or health is in immediate danger because of the decision in the Notice of
Action letter, you or the doctor acting on your behalf can ask for a quick (expedited) appeal by calling us. If you
call us to request a quick appeal, you do not need to send Molina this form.
If you want help in completing this form, please call 1-855-882-3901
Is the Member or a healthcare Provider (on behalf of you) requesting this appeal?
☐ Member ☐ Healthcare Provider
Date: ________________________
Member INFORMATION:
LAST NAME: FIRST NAME: MI: Current Address: Apt. City: State: Zip: Phone number: Email Address: Doctor’s Name: What results are you hoping for from this appeal?
Please attach any information that will help us to understand your medical case and your appeal and send it to:
Molina Healthcare Appeals Department
P.O. Box 40309
North Charleston, SC 29423-0309
Fax Number: 1-877-823-5961
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How to Pick a PCP - Checklist
A Primary Care Provider (PCP) is the health care Provider who will help you with most of your medical needs.
Your PCP will give you care, offer advice, and refer you to a specialist when necessary. It is important that you
find a PCP who meets your needs. The following checklist will help you when you are picking a PCP.
☐☐ Look in Molina Healthcare’s Provider Directory to find a list of contracted PCPs. You can view the Provider
Directory online at www.MolinaHealthcare.com. If you need help, call Molina Healthcare of South Carolina
Member Services Department 1-855-882-3901 (Hard-of-Hearing Relay Service 711).
☐☐ Is the PCP’s office located in an area that is convenient for you?
☐☐ Does the PCP have office hours that are convenient for you and your family? This is especially important if
you have family Members who work or attend school.
☐☐ Will the PCP treat all of the Members of your family, or is the Provider specifically for children or adults?
☐☐ Your PCP’s gender may be important to you. Would you prefer to see a male or female PCP?
☐☐ Do you or your family Members speak a language other than English? Check to see if there is a PCP
available who speaks your language.
Picking a PCP is important. When you find a good PCP, you can develop a lasting relationship that will ensure a
health care partnership for years to come.
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First Visit - Check List
Now that you have picked a PCP, be sure to schedule a check-up soon; even if you’re not sick. During the
appointment, you will have a chance to get to know your PCP and to ask a number of questions that will help
you develop a good relationship.
Here are some things you should do to get ready for your first appointment:
☐☐ Make a list of the medications that you are currently taking.
☐☐ Make a list of any allergies that you have.
☐☐ If you have not been feeling well, make a list of your symptoms and take it to your appointment.
☐☐ Make a list of anything you would like to discuss with your PCP.
☐☐ Allow time to arrive at your appointment a few minutes early so that you have time to check in at the
reception desk.
☐☐ Remember to take your Molina Member ID card and Medicaid card with you to your appointment.
During the appointment, be sure to ask your PCP:
☐☐ How long should I expect to wait for a regular appointment?
☐☐ Can I be seen on the same day if the need is urgent?
☐☐ Who should I call if I have problems after hours? Remember, Molina’s Nurse Advice Line is open 24 hours a
day, 7 days a week to answer your health care questions when your PCP is not available.
☐☐ What should I do if I need to see a specialist?
☐☐ What should I do if I have to cancel an appointment?
☐☐ What if I think of a question after I leave the office?
☐☐ When do I need to return for another visit?
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Your Health Providers:
Name: Phone: Name: Phone: Name: Phone: Emergency Room: Phone: Pharmacy: Phone: This handbook is your guide to your health care plan benefits. Please read this handbook carefully. It explains how
to get health care services. It gives you facts on the extra benefits that you get as a Molina Healthcare of South
Carolina Member. If you need help, it will tell you whom to call.
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4105 Faber Place Drive, Suite 120
Charleston, SC 29405
MolinaHealthcare.com
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