2022 Agreement and Individual Evidence ofCoverage - Molina Healthcare

MolinaHealthcareof Texas, Inc Marketplace

2022 |Agreement and Individual Evidence of Coverage

Molina Healthcare of Texas

1660 N Westridge Circle Irving, TX 75038 1 (888) 560-2025

This Consumer Choice Health Benefit Plan, either in whole or in part, does not provide state-mandated health benefits normally required in evidences of coverage in Texas. This standard health benefit plan may provide a more affordable health plan for you although, at the same time, it may provide you with fewer health plan benefits than those normally included as state-mandated health benefits in Texas. Please consult with your insurance agent to discover which state-mandated health benefits are excluded in this evidence of coverage.

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Right to Return: Newly enrolled Subscribers have the right to return this Agreement until midnight of the tenth day after the date on which the Subscriber receives the Agreement, by returning the Agreement to Molina or an agent of Molina. No reason need be stated for the return. Molina will treat this Agreement as if it had never been issued and will return all Premium Payments to the Subscriber. If the Subscriber returns this Agreement under this provision, they will be responsible for payment of any health care service they or a Dependent received before they returned the Agreement.

Notice of Rights: Molina Healthcare, a health maintenance organization (HMO) plan provides no benefits for services a Member receives from out-of-network providers, with specific exceptions as described in your evidence of coverage and below. A Member has the right to an adequate network of in-network physicians and providers (known as network physicians and providers). If a Member believes that the network is inadequate, the Member may file a complaint with the Texas Department of Insurance at: tdi.consumer/complfrm.html. If Molina approves a Referral for out-ofnetwork services because no network physician or provider is available, or if the Member has received out-of-network emergency care, Molina must, in most cases, resolve the outof-network physician's or provider's bill so that the Member only has to pay any applicable in-network Copayment, Percentage Copayment, and Deductible amounts. A Member may obtain a current directory of network physicians and providers at the following website: or by calling 1 (888) 560-2025 for assistance in finding available network physicians and providers. If the Member relied on materially inaccurate directory information, you may be entitled to have a claim by an out-of-network physician or provider paid as if it were from a network physician or provider, if a Member presents a copy of the inaccurate directory information to Molina, dated not more than 30 days before the Member received the service.

Premium Increase Notice: Premium may be increased upon the Renewal Date of this Agreement; this Agreement may be subject to non- renewal for Dependents surpassing the maximum Dependent age limit. In the event of a rate increase, We will provide written notice of the increase at least 60 days before the increase takes effect, which will include the dollar amount of the premium before and after the change, and the percentage change between the two.

ADDITIONAL NOTICE: THIS AGGREEMENT IS NOT A MEDICARE SUPPLEMENT. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company.

THE INSURANCE AGREEMENT UNDER WHICH THIS EVIDENCE OF COVERAGE IS ISSUED IS NOT AN AGREEMENT OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM.

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Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal.

Molina Healthcare of Texas To get information or file a complaint with your insurance company or HMO:

Call: Customer Support at 1 (888) 560-2025 Toll-free: 1 (888) 560-2025 Email: TXMemberInquiryResearchAndResolution@ Online: Mail: 1660 N Westridge Circle Irving, TX 75038

The Texas Department of Insurance To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439 File a complaint: tdi. Email: ConsumerProtection@tdi. Mail: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

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?Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamaci?n o con su prima de seguro, llame primero a su compa??a de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, por su nombre en ingl?s) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, tambi?n debe presentar una queja a trav?s del proceso de quejas o de apelaciones de sucompa??a de seguros o HMO. Si no lo hace, podr?a perder su derecho para apelar.

Molina Healthcare of Texas Para obtener informaci?n o para presentar una queja ante su compa??a de seguros o HMO:

Llame a: Customer Support 1 (888) 560-2025 Tel?fono gratuito: 1 (888) 560-2025 Presente una queja en: TXMemberInquiryResearchAndResolution@ En l?nea: Direcci?n postal: 1660 N Westridge Circle Irving, TX 75038

El Departamento de Seguros de Texas Para obtener ayuda con una pregunta relacionada con los seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439 Presente una queja en: tdi. Correo electr?nico: ConsumerProtection@tdi. Direcci?n postal: MC 111-1A, P.O. Box 149091, Austin, TX 78714-9091

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MOLINA REFERENCE GUIDE

Service

Emergency Services

Need

? Treatment of an Emergency Medical Condition

Where to Go Call 911, or go to any hospital emergency room, even if it is a Non-Participating Provider or outside of the Service Area. Call your Doctor

Getting Care

? Urgent Care o Minor Illnesses o Minor Injuries

? Virtual Care ? Physicals and check-ups ? Preventive care ? Immunizations (shots)

? Find or change your doctor

? View benefits and Member

Online Access

Handbook

? View or Print ID card

? Track claims

Urgent Care Centers Find a provider or urgent care center ProviderSearch

Virtual Care molinamarketplace 1-800-TELADOC

24-Hour Nurse Advice Line 1 (888) 275-8750 (English) 1 (866) 648-3537 (Spanish) Go to

Download the Molina Mobile App

Visit the Provider Directory ProviderSearch

Plan Details

? Answers about your plan, programs, services, or prescription drugs

? ID card support ? Access to care ? Prenatal care ? Well-child visits ?

Billing and Payment Services

? Premium Payment Questions

Eligibility and Enrollment

? Eligibility questions

? Add a Dependent ? Report change of address or

income

Molina Member Services 1 (888) 560-2025 Monday through Friday, 8:00 a.m. to 6:00 p.m. (Local Time)

Go to

1 (844) 359-0201 Monday through Friday, 8:00 a.m. to 6:00 p.m. (Mountain Time)

Go to 1 (800) 318-2596 Go to

Interpreter Services: Molina offers interpreter services for any Member who may need language assistance to understand and obtain health coverage under this Agreement. Molina provides these services at no additional cost to the Member. Molina will provide oral interpretation services and written translation services for any materials vital to a Member understanding their health care coverage. Members who are deaf or hard of hearing can use the Telecommunications Relay Service by dialing 7-1-1.

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