What Does Molina Insurance Cover? Medicaid, Medicare, Marketplace, and CHIP

Molina Healthcare insurance covers doctor visits, hospital stays, emergency care, prescription drugs, behavioral health, and preventive services across its Medicaid, Medicare Advantage, Children’s Health Insurance Program (CHIP), and Affordable Care Act Marketplace plans. What you actually pay and which extras you get depend on which plan you have and which state you live in. Molina operates in 23 states, and benefits differ meaningfully from one program to the next, so the short answer to “what does Molina insurance cover” is: the standard set of medical care, plus plan-specific extras like dental, vision, transportation, over-the-counter allowances, and fitness benefits for certain members.¹

The Core Benefits Every Molina Plan Includes

Regardless of program, Molina plans cover the services most people expect from health insurance:

Preventive care, wellness screenings, and primary care visits
Specialist visits
Inpatient hospital stays and outpatient procedures
Emergency room care, with no prior authorization required
Lab work, X-rays, and other diagnostic imaging
Prescription drugs
Mental health care and substance use disorder treatment
Maternity care

Beyond that baseline, the picture changes based on which Molina plan you have.

What Molina Medicaid Covers

Molina’s Medicaid plans carry the broadest benefits and the lowest costs. In Ohio, Medicaid members pay $0 copays for all covered services.² In Nebraska, prescriptions filled at a network pharmacy also cost nothing.³

Dental and vision are included in many state Medicaid plans. Nebraska covers preventive dental services (exams, fluoride), restorative work like crowns and root canals, and orthodontics.³ Illinois Medicaid covers oral surgery, X-rays, fillings, dentures, and cleanings every six months for both children and adults.⁴ Iowa’s Medicaid plan includes one routine eye exam per year, eyeglasses, hearing exams, and hearing aids.⁵

Free non-emergency medical transportation is standard. Michigan Medicaid covers rides to doctor visits, lab appointments, dental services, and prescription pick-ups, and may also provide bus tokens or mileage reimbursement. Requests should be made at least three business days in advance.⁶

Some services require prior authorization. In Ohio, that includes home health care, physical therapy, and durable medical equipment like wheelchairs and walkers; your provider has to request the authorization on your behalf.⁷

What Molina Medicare Advantage and Dual-Eligible Plans Cover

Molina’s Medicare plans are structured as HMO Dual Eligible Special Needs Plans (D-SNPs) for people who qualify for both Medicare and Medicaid. They cover everything Original Medicare covers and add supplemental benefits.

Ohio’s Molina Complete Care plan includes preventive and comprehensive dental, vision, an over-the-counter benefit, a fitness benefit, and a rewards program for completing health screenings.⁸ The Texas D-SNP plan loads a $168 combined monthly allowance onto a prepaid “MyChoice card” that members use for OTC health items, OTC hearing aids, transportation to health-related locations, and food and produce if they have qualifying chronic conditions. Unused amounts don’t roll over to the next month.⁹

Michigan dual-eligible members get the Silver&Fit fitness program, which includes a gym membership at participating centers, group classes, and home fitness kits.¹⁰ The Michigan plan also includes long-term services and supports through the MI Health Link program, covering home and community-based services for people with ongoing personal care needs, and habilitation supports for people with intellectual or developmental disabilities.¹¹ In Illinois, the HealthChoice MLTSS program includes five waiver programs covering elderly members, people with physical disabilities, people with brain injuries, people living with HIV or AIDS, and residents of supportive living facilities.¹²

Medicare and dual-eligible members can also earn rewards through Molina’s Healthy Actions program by completing routine screenings such as an annual wellness visit, flu shot, and colon cancer screening. Rewards load onto a Benefits Mastercard Prepaid Card for use on healthy food and produce at participating retailers.¹³

What Molina Marketplace Plans Cover

Molina’s ACA Marketplace plans are sold in Bronze, Silver, and Gold tiers to people who don’t have employer coverage and earn too much for Medicaid.¹⁴ Preventive care — annual wellness exams, routine screenings, and preventive prescription drugs — is covered at no charge across all tiers.¹⁵

Cost-sharing on everything else varies by tier. An Ohio Gold plan charges $20 copays for primary care, $50 for specialists, and $15 for blood work, none of which count against the deductible. CT scans, MRIs, emergency room visits, and hospital stays run 25% coinsurance.¹⁶ A Texas Marketplace “Zero Plan” charges $0 for both emergency room and urgent care at participating providers.¹⁷ A California Platinum plan charges $150 per ER visit, waived if you’re admitted.¹⁸

Marketplace members generally have to stay in-network. Out-of-network services aren’t covered unless Molina pre-authorizes them.¹⁶

What Molina CHIP Covers for Children

Molina’s CHIP plans cover children in families that earn too much for Medicaid but can’t afford private insurance. Benefits include regular medical and dental checkups, prescription drugs, hospital care, lab tests, vision and hearing care, mental health services, and treatment for pre-existing conditions.¹⁹

Mississippi’s Molina CHIP plan sets a $2,000 annual maximum for dental services and a $4,200 lifetime cap on orthodontia per child. Vision coverage includes one exam and one pair of glasses per year, plus a $100 annual credit toward frames, lenses, or contacts. Members can fill six prescriptions a month, with more if medically necessary.²⁰

Mental Health and Substance Use Treatment

Behavioral health is covered across every plan type. California Medicaid members can get a mental health assessment with a licensed provider at no cost, and no referral is needed for non-specialty services. Covered outpatient care includes individual, family, and group therapy, along with medication management. Couples counseling is not covered.²¹

Washington Medicaid members can self-refer for behavioral health evaluation and outpatient care. Coverage extends to Applied Behavior Analysis for autism, crisis stabilization, inpatient psychiatric admissions, peer support, and medication management. Substance use services include withdrawal management, residential treatment at various intensity levels, and opiate use disorder treatment.²²

On the Marketplace side, California plans include inpatient psychiatric care, intensive outpatient programs, psychological testing, Medication-Assisted Treatment for substance use, and diagnosis and treatment of Autism Spectrum Disorder including Applied Behavioral Analysis. Emergency behavioral health is covered without prior authorization whether or not the provider is in-network. Molina states that it follows the federal Mental Health Parity and Addiction Equity Act, so behavioral health cost-sharing and treatment limits are no more restrictive than those for medical and surgical care.²³

Prescription Drugs

For Medicaid, Molina follows each state’s preferred drug list. Michigan uses the state-mandated Michigan Medicaid Common Formulary.²⁴ Washington uses the state Health Care Authority’s preferred drug list and only covers drugs in the Medicaid Drug Rebate Program; medications for weight loss, erectile dysfunction, infertility, and cosmetic purposes are excluded.²⁵

Medicare plans use a Molina-developed formulary. Some drugs require prior authorization or step therapy, meaning you have to try a lower-cost drug first before the plan covers a more expensive one. Molina may add or remove drugs during the year but generally gives at least 30 days’ notice. Members with three or more chronic conditions who take at least eight maintenance medications may qualify for Molina’s free Medication Therapy Management program, which reviews all prescriptions, OTC drugs, and herbal supplements.²⁶

Telehealth

Virtual visits are covered on the same basis as in-person care across Molina’s plans.²⁷ Many Medicaid plans offer free virtual care through Teladoc, available 24/7 by phone, video, or app with no appointment needed. Common uses include cold and flu symptoms, sore throat, allergies, respiratory infections, sinus problems, and skin issues. Virtual care is for non-emergency situations, and Teladoc providers cannot prescribe DEA-controlled substances.²⁸ Telehealth also covers prenatal and postpartum care, behavioral health, and chronic condition monitoring.²⁹

Pregnancy and Newborn Care

Molina Medicaid covers prenatal care, OB/GYN and hospital services, labs and diagnostic tests, childbirth education classes, and care for pregnancy complications. High-risk pregnancies get dedicated nurse care managers. After delivery, the plan covers one medically necessary postpartum home visit for newborn care and assessment, with routine follow-up expected within three to eight weeks of birth (earlier for cesarean sections). The newborn automatically becomes a plan member at birth, including newborn screenings.³⁰

What Molina Doesn’t Cover

Marketplace plans in particular carry a list of exclusions. Based on Florida, Ohio, and Wisconsin summary of benefits documents, Molina Marketplace plans commonly do not cover:

Acupuncture
Bariatric surgery
Cosmetic surgery
Adult dental care (on many plans)
Adult routine eye care
Hearing aids
Infertility treatment
Long-term care
Non-emergency care outside the United States
Private-duty nursing
Routine foot care
Weight loss programs

These exclusions come from Florida, Ohio, and Wisconsin plan documents.³¹¹⁶³²

Service caps are also common. Florida Marketplace plans limit rehabilitation services (physical, speech, occupational, and cardiac rehab combined) to 35 visits per year, home health care to 60 visits, and skilled nursing to 60 days.³¹ Wisconsin’s version drops home health to 20 visits and skilled nursing to 45 days.³²

How to Confirm What Your Plan Covers

Molina operates in Arizona, California, Connecticut, Florida, Georgia, Idaho, Illinois, Iowa, Kentucky, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, New Mexico, New York, North Carolina, Ohio, South Carolina, Texas, Utah, Virginia, Washington, and Wisconsin.¹ Not every plan type is offered in every state, and the same program can look different from one state to the next. For an authoritative list of what your plan covers, including cost-sharing, service caps, and prior authorization rules, check your Member Handbook or Summary of Benefits.

1
Molina Healthcare. Molina Healthcare Home Page
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Molina Healthcare. Ohio Medicaid Covered Services
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Molina Healthcare. Nebraska Medicaid Benefits
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Molina Healthcare. Illinois Medicaid Dental Coverage
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Molina Healthcare. Iowa Medicaid Benefits and Services
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Molina Healthcare. Michigan Medicaid Transportation
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Molina Healthcare. Ohio Medicaid Prior Authorizations
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Molina Healthcare. Ohio Medicare Plans
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Content.MedicareAdvantage.com. Molina Medicare Complete Care Plus Texas Summary of Benefits
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Molina Healthcare. Michigan Dual Options Fitness Benefit
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Molina Healthcare. Michigan Long Term Services and Supports
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Molina Healthcare. Illinois MLTSS Waiver Programs
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Molina Healthcare. Michigan Dual Options Healthy Actions Rewards Program
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Molina Marketplace. About Molina Healthcare
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Molina Marketplace. Mississippi 2025 Marketplace Plan Brochure
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Molina Marketplace. Ohio Gold 1 LCS Summary of Benefits
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Molina Marketplace. Texas Zero Plan Summary of Benefits
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Molina Marketplace. California Platinum 90 HMO Summary of Benefits
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Texas Health and Human Services. CHIP
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Molina Healthcare. Mississippi CHIP Benefits and Rewards
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Molina Healthcare. California Medi-Cal Mental Health Services
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Molina Healthcare. Washington Medicaid Behavioral Health
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Molina Marketplace. California Marketplace Behavioral Health
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Molina Healthcare. Michigan Medicaid Drug Formulary
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Molina Healthcare. Washington Medicaid Drug Formulary
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Molina Healthcare. Illinois Medicare Prescription Drug Coverage
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Molina Healthcare. Telemedicine Telehealth Services and Virtual Visits
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Molina Healthcare. Texas Medicaid Virtual Care
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Molina Healthcare. Ohio Provider Telehealth Resource Guide
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Molina Healthcare. Kentucky Passport Pregnancy Care
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Molina Healthcare. Florida Gold 1 Summary of Benefits
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Molina Healthcare. Wisconsin Silver 8 Summary of Benefits