MEDICARE Advance Screening 20 22 - PIMSCO
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20 Advance Screening
22 MEDICARE
This document is not intended forThismarketing
document purposes or public distribution
is not intended for marketing and is considered
purposes “Confidential
or public distributionInformation”, as defined
and is considered in your Agreement
“Confidential with
Information”, asMolina
defined in your Agreement with Molina
Healthcare, Inc. (“MHI”). Distribution and reproduction
Healthcare, of this
Inc. (“MHI”). document
Distribution is reproduction
and strictly prohibited and
of this may be grounds
document is strictlyfor immediate
prohibited termination
and of yourfor
may be grounds Agreement
immediateand
termination of your Agreement and any
any other legal remedies MHI may havelegal
other . Theremedies
information
MHIinmay
this have
document is pending CMS
. The information approval
in this documentandismay be subject
pending to change.
CMS approval and may be subject to change.
To our Strategic Partners,
At Molina Healthcare, we’re grateful to your dedication and support you have given Molina, especially in ever-
changing times. You’re an important part of our mission to help those who need it most. As a trusted partner
to the community, your partnership makes it possible for many Molina members to lead healthier lives. Your
dedication makes a lasting difference for our beneficiaries, and everyone we serve.
We’ve made improvements to our plan offerings, market expansion and our services to support you in growing
your business with Molina. As one of our Strategic Partners, we are excited to share our advance screening of our
2022 product offerings and market expansion plan with you.
Wishing you a healthy and successful year!
Sincerely,
Tom Wilfong
SVP, Medicare Segment
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
2 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
Table of Contents
About Molina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 New York. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Ohio. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Why Members Love Molina. . . . . . . . . . . . . . . . . . . 5
South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
National Footprint 2022 . . . . . . . . . . . . . . . . . . . . . 7 Texas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
National Benefit Changes. . . . . . . . . . . . . . . . . . . . 8
Virginia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
State Pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Washington. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Arizona. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wisconsin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
California. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Certification Overview 2022 . . . . . . . . . . . . . . . . 70
Florida. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Broker Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Kentucky. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Broker Channel/Sales Managers. . . . . . . . . . . . . 73
Massachusetts. . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Michigan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
New Mexico. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
3 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
About Molina
Our Mission Our Vision Our Values
Our mission is to provide We will distinguish • Integrity Always
quality health care ourselves as the low cost,
• Absolute Accountability
to people receiving most effective and
government assistance. reliable health plan • Supportive Teamwork
delivering government-
sponsored care. • Honest and Open
Communication
• Member and Community
Focused
Our History
• Founded in 1980
Total number of members
• 4,381,052 (as of May 18, 2021)
Fortune 500 ranking
• Ranked 155 in Fortune 500 with revenues over $19B
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
4 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
Why Members Love Molina
24 Hour Nurse Nutritional Medication
Advice Line Counseling Management
Members can call anytime, Telephonic nutritional Provides annual monitoring
day or night, to speak with counseling, and referrals for for patients on persistent
a registered nurse about members for a set number of medications and medication
illnesses or injuries (available individual in-person or group reconciliation post
in both English and Spanish). sessions every calendar year. in-patient discharge.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
5 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
Why Members Love Molina - (cont.)
Case Management Molina Mobile App Member Services
A team of Registered Nurses Members can manage This team helps the member
(RNs) arrange individual their health care anytime, get the most of their plan by
services for members whose anywhere: view Member ID assisting them in accessing
needs include ongoing Card, find a doctor or their benefits (Medicare and
medical care, home health facility, use the Nurse Medicaid). Our U.S. based
care, rehabilitation services, Advice Line and more. staff can answer any
and preventive services This is available on both question that a member
in coordination with the App Store and Google Play. may have regarding their
member’s PCP. health plan benefits.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
6 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
National Footprint 2022
2021 2022 2022 2022
Existing Expansion Aquisition Total
Service Area State Counties Counties Counties Counties
AZ 0 0 3 3
CA 5 0 0 5
FL 7 10 0 17
ID 21 0 0 21
KY 0 0 16 16
MA 0 0 8 8
MI 41 8 0 49
NM 23 1 0 24
NY 0 0 6 6
OH 71 10 0 81
SC 43 2 0 45
TX 52 19 0 71
UT 10 0 0 10
2021 Existing States
VA 0 0 133 133
2022 Expansion Counties
WA 17 2 0 19
2022 Aquisition States
WI 29 4 0 33
County Growth: 69.5% Total 319 56 166 541
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
7 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
National Benefit Changes
New for 2022
Flex Card Benefit:
• Flex card preloaded with a set amount depending on the member’s eligibility and plan.
• Promote member choice and flexibility within our in-network providers and improve overall quality of life,
especially for those with chronic conditions.
• Flexible and convenient debit card that allows members to use it for everything from:
» Dental » Service Animal Supplies*
» Vision » Pest Control*
» OTC Allowance » Mental Health & Wellness
Applications* (for phone or tablet)
» Transportation
» Non-Medicare-Covered Genetic
» Food & Produce* Test Kit*
*Special Supplemental Benefits for the Chronically Ill (SSBCI)
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
8 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
National Benefit Changes - (cont.)
Part B Buybacks: Part D Senior
Lowers the monthly cost
Savings Program:
of the members Medicare
• Savings program
Part B monthly premium.
available on most Molina
MAPD plans.
• Helps those members
with diabetes save on
the monthly insulin
prescription costs.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
9 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.
Arizona
Service Area
2021 Existing Counties
2022 Expansion Counties
2022 Aquisition Counties
Gila
Maricopa
2022 Product Offerings:
• 1 D-SNP Pinal
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
10 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.ACQUISITION
Arizona – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H8845-001
Service Area Gila, Maricopa, Pinal
Plan Type D-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Vision, OTC Allowance, Flex Card* (Service Animal Supplies, Mental Health &
Supplemental Benefits
Wellness Applications)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
11 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.California
Service Area
2021 Existing Counties
2022 Expansion Counties
2022 Aquisition Counties
2022 Product Offerings*:
• 2 D-SNP San Bernardino
• 2 MAPD Los Angeles
Riverside
San Diego Imperial
*Service area varies by plan
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
12 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.California – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H5810-001
Service Area Los Angeles, Riverside, San Bernardino, San Diego
Plan Type D-SNP (QMB, QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
13 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.California – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H5810-013
Service Area Imperial
Plan Type D-SNP (QMB, QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
14 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
California – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H5810-014
Service Area Imperial, Los Angeles, Riverside, San Bernardino, San Diego
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $30
Prescription Deductible $125
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
15 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
California – Plan Information
Plan Marketing Name Molina Medicare Choice Care Select
Plan Number H5810-015
Service Area Imperial, Los Angeles, Riverside, San Bernardino, San Diego
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $450/day (Days 1-4) $0/day (Days 5-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $50
Prescription Deductible $480 (Medicare defined)
Supplemental Benefits Part B Buyback, Fitness, OTC Allowance
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
16 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Florida
Baker Duval
Clay
Service Area
2021 Existing Counties
Seminole
2022 Expansion Counties Orange
2022 Aquisition Counties Pasco
Osceola
Hillsborough
Pine
Polk
llas
DeSoto
Sarasota
2022 Product Offerings: Glades
Hendry Palm Beach
• 1 C-SNP
• 2 D-SNP Broward
• 2 MAPD
Miami–Dade
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
17 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Florida – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H8130-001
Broward, Hillsborough, Miami-Dade, Palm Beach, Pasco, Pinellas, Polk, Baker, Clay, DeSoto, Duval,
Service Area
Glades, Hendry, Orange, Osceola, Sarasota, Seminole
Plan Type D-SNP (QMB, QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $3,400
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
18 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Florida – Plan Information
Plan Marketing Name Molina Medicare Connect Care
Plan Number H8130-008
Baker, Broward, Clay, DeSoto, Duval, Glades, Hendry, Hillsborough, Miami-Dade, Orange, Osceola,
Service Area
Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole
Plan Type C-SNP
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $10
Prescription Deductible $0
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
19 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Florida – Plan Information
Plan Marketing Name Molina Medicare Complete Care Select
Plan Number H8130-009
Baker, Broward, Clay, DeSoto, Duval, Glades, Hendry, Hillsborough, Miami-Dade, Orange, Osceola,
Service Area
Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole
Plan Type D-SNP (SLMB, QI & QDWI)
Premium TBD
Maximum Out of Pocket $3,400
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $10
Prescription Deductible $480 (Medicare defined)
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
20 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Florida – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H8130-010
Baker, Broward, Clay, DeSoto, Duval, Glades, Hendry, Hillsborough, Miami-Dade, Orange, Osceola,
Service Area
Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $10
Prescription Deductible $125
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
21 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Florida – Plan Information
Plan Marketing Name Molina Medicare Choice Care Select
Plan Number H8130-011
Baker, Broward, Clay, DeSoto, Duval, Glades, Hendry, Hillsborough, Miami-Dade, Orange, Osceola,
Service Area
Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $450/day (Days 1-4) $0/day (Days 5-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $50
Prescription Deductible $480 (Medicare defined)
Supplemental Benefits Part B Buyback, Fitness, OTC Allowance
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
22 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Idaho Bo
un
da
ry
Bonner
Kootenai
Service Area
2021 Existing Counties
2022 Expansion Counties z
Ne rce
Pe
2022 Aquisition Counties
2022 Product Offerings*:
Fremont
e
tt
ye
• 1 D-SNP Pa Gem
Boise Je
ffe
rso Madi
C n son
an
• 1 FIDE-SNP yo
n Ada
Bonneville
Elmore
• 2 MAPD Bingham
oka
Minid
Po
Ba
we
n
r
no
Tw
ck
Owyhee inF
all
s Cassia
*Service area varies by plan
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
23 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Idaho – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H5628-008
Ada, Bannock, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Elmore, Fremont,
Service Area
Gem, Jefferson, Kootenai, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Twin Falls
Plan Type FIDE-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
24 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Idaho – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H5628-009
Service Area Ada, Canyon
Plan Type MAPD
Premium $0
Maximum Out of Pocket $5,000
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $35
Prescription Deductible $100
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
25 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Idaho – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H5628-010
Service Area Twin Falls
Plan Type MAPD
Premium $0
Maximum Out of Pocket $5,750
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $30
Prescription Deductible $125
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
26 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Idaho – Plan Information
Plan Marketing Name Molina Medicare Complete Care Select
Plan Number H5628-011
Ada, Bannock, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Elmore, Fremont,
Service Area
Gem, Jefferson, Kootenai, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Twin Falls
Plan Type D-SNP (QMB, SLMB, QI, QDWI)
Premium TBD
Maximum Out of Pocket $2,000
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $10
Prescription Deductible $480 (Medicare defined)
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
Plans with 20% Cost Share for Medicare-Covered Benefits – Costs may be as low as $0, depending Medicaid eligibility
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
27 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Kentucky
2022 Product Offerings:
• 1 D-SNP
• 1 MAPD
Service Area
2021 Existing Counties
ll
2022 Expansion Counties rro
Tri
Ca
mb
le
2022 Aquisition Counties Henry
Oldham
Shelby
Jefferson
Spencer
Bullitt
Meade
Nelson n
Breckinridge gto
s hin
Wa
Hardin
Marion
Larue
Grayson
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
28 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.ACQUISITION
Kentucky – Plan Information
Plan Marketing Name Passport Advantage
Plan Number H1799-001
Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson,
Service Area
Oldham, Shelby, Spencer, Trimble, Washington
Plan Type D-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
29 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Kentucky – Plan Information
Plan Marketing Name Passport Medicare Choice Care
Plan Number H1799-002
Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, Jefferson, Larue, Marion, Meade, Nelson,
Service Area
Oldham, Shelby, Spencer, Trimble, Washington
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $30
Prescription Deductible $125
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
30 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Massachusetts 2022 Product Offerings*:
• 2 FIDE-SNP
• 1 MAPD
Essex
Middlesex
Suffolk
Worcester Norfolk
k
Norfolk
ol
ff
Su
Norfolk
Hampden
Plymouth
Bristol
Service Area
2021 Existing Counties
2022 Expansion Counties
2022 Aquisition Counties
*Service area varies by plan
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
31 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.ACQUISITION
Massachusetts – Plan Information
Plan Marketing Name Senior Whole Health Medicare Complete Care
Plan Number H2224-001
Service Area Bristol, Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, Worcester
Plan Type FIDE-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Fitness, Vision, OTC Allowance, Flex Card* (Food & Produce), Transportation for
Supplemental Benefits
Non-medical Needs*
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
32 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.ACQUISITION
Massachusetts – Plan Information
Plan Marketing Name Senior Whole Health Medicare Complete Care
Plan Number H2224-003
Service Area Bristol, Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, Worcester
Plan Type FIDE-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Fitness, Vision, OTC Allowance, Flex Card* (Food & Produce), Transportation for
Supplemental Benefits
Non-medical Needs*
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
33 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Massachusetts – Plan Information
Plan Marketing Name Senior Whole Health Medicare Choice Care
Plan Number H2879-002
Service Area Suffolk
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $30
Prescription Deductible $125
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
34 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Michigan
Service Area Cha
r levo
ix
Mont-
2021 Existing Counties Antrim Otsego morency
au
an
el
Le
2022 Expansion Counties
rd
ka
fo
Grand Oscoda
s
w
ka
Benzie
ra
Traverse
l
Ka
C
2022 Aquisition Counties e on
ee ke m Iosco
i st Wexford au om Ogemaw
an i ss sc
M M Ro
Arenac
Mason Lake Osceola Clare
Huron
Oceana Mecosta Bay
Newaygo
Tuscola Sanilac
2022 Product Offerings: aw
gon
Montcalm t n
tio gi
Sa
ske
ra
G
Mu
Lapeer
• 1 MAPD Ottawa
Kent
Shia-
wassee
Genesee St. Clair
• 2 D-SNP
b
com
Oakland
Liv-
Ma
Allegan Barry ingston
Wayne
Washtenaw
e
ch e ee ro
an al w on
Br sd na M
Hill Le
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
35 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Michigan – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H5926-001
Allegan, Arenac, Barry, Bay, Clare, Genesee, Gratiot, Huron, Kent, Lake, Lapeer, Livingston, Macomb,
Mason, Mecosta, Monroe, Montcalm, Muskegon, Newaygo, Oakland, Oceana, Osceola, Ottawa, Saginaw,
Service Area Sanilac, Shiawassee, Tuscola, Washtenaw, Wayne, Antrim, Branch, Charlevoix, Crawford, Grand Traverse,
Kalkaska, Leelanau, Manistee, Missaukee, Otsego, Roscommon, Wexford, Benzie, Hillsdale, Iosco, Lenawee,
Montmorency, Ogemaw, Oscoda, St. Clair
Plan Type D-SNP (QMB, QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
36 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Michigan – Plan Information
Plan Marketing Name Molina Medicare Complete Care Select
Plan Number H5926-005
Allegan, Arenac, Barry, Bay, Benzie, Clare, Genesee, Gratiot, Hillsdale, Huron, Iosco, Kent, Lake, Lapeer,
Lenawee, Livingston, Macomb, Mason, Mecosta, Monroe, Montcalm, Montmorency, Muskegon, Newaygo,
Service Area Oakland, Oceana, Ogemaw, Osceola, Oscoda, Ottawa, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola,
Washtenaw, Wayne, Antrim, Branch, Charlevoix, Crawford, Grand Traverse, Kalkaska, Leelanau, Manistee,
Missaukee, Otsego, Roscommon, Wexford
Plan Type D-SNP (SLMB, QI & QDWI)
Premium TBD
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $20
Prescription Deductible $480 (Medicare defined)
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
37 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Michigan – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H5926-006
Allegan, Arenac, Barry, Bay, Benzie, Clare, Genesee, Gratiot, Hillsdale, Huron, Iosco, Kent, Lake, Lapeer,
Lenawee, Livingston, Macomb, Mason, Mecosta, Monroe, Montcalm, Montmorency, Muskegon, Newaygo,
Service Area Oakland, Oceana, Ogemaw, Osceola, Oscoda, Ottawa, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola,
Washtenaw, Wayne, Antrim, Branch, Charlevoix, Crawford, Grand Traverse, Kalkaska, Leelanau, Manistee,
Missaukee, Otsego, Roscommon, Wexford
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $30
Prescription Deductible $125
Hearing, Meals, Fitness, Dental, Vision, Transportation, OTC Allowance, Flex Card* (Food &
Supplemental Benefits Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
38 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.New Mexico
Rio Arriba Taos
San Juan
Los
Alamos
Mora
McKinley Sandoval
e
aF
Service Area San Miguel
nt
Sa
2021 Existing Counties Bernalillo
Cibola Guadalupe
2022 Expansion Counties Valencia
Torrance
2022 Aquisition Counties
De Baca
Roosevelt
Socorro
Lincoln
Chaves
Sierra
2022 Product Offerings: Grant
Otero
• 3 MAPD Dona Ana
Luna
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
39 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.New Mexico – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H9082-009
Bernalillo, Chaves, Cibola, DeBaca, Dona Ana, Grant, Guadalupe, Lincoln, Los Alamos, Luna,
Service Area McKinley, Mora, Otero, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Sierra,
Socorro, Torrance, Valencia, Taos
Plan Type MAPD
Premium TBD
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance Original Medicare Cost Share
PCP Copay/Coinsurance 20%
Specialist Copay/Coinsurance 20%
Prescription Deductible $480 (Medicare defined)
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
40 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
New Mexico – Plan Information
Plan Marketing Name Molina Medicare Choice Care Plus
Plan Number H9082-010
Bernalillo, Chaves, Cibola, DeBaca, Dona Ana, Grant, Guadalupe, Lincoln, Los Alamos, Luna,
Service Area McKinley, Mora, Otero, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Sierra,
Socorro, Taos, Torrance, Valencia
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $10
Prescription Deductible $125
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
41 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
New Mexico – Plan Information
Plan Marketing Name Molina Medicare Choice Care Select
Plan Number H9082-011
Bernalillo, Chaves, Cibola, DeBaca, Dona Ana, Grant, Guadalupe, Lincoln, Los Alamos, Luna,
Service Area McKinley, Mora, Otero, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Sierra,
Socorro, Taos, Torrance, Valencia
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $450/day (Days 1-4) $0/day (Days 5-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $40
Prescription Deductible $480 (Medicare defined)
Supplemental Benefits Part B Buyback, Fitness, OTC Allowance
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
42 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.New York
Service Area
2021 Existing Counties
2022 Expansion Counties
2022 Aquisition Counties
- West-
er
West-
chester chester
2022 Product Offerings:
Bro
nx
New York
Qu
• 1 D-SNP
een
Kings s Nassau
• 1 FIDE-SNP Bro
nx
New York
Qu
een
Kings s Nassau
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
43 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Nassau
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.ACQUISITION
New York – Plan Information
Plan Marketing Name Senior Whole Health of New York Nursing Home Certifiable
Plan Number H5992-007
Service Area Bronx, Kings, Nassau, New York, Queens, Westchester
Plan Type FIDE-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Supplemental Benefits Fitness, Vision, OTC Allowance, Flex Card* (Food & Produce)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
44 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
New York – Plan Information
Plan Marketing Name Senior Whole Health Medicare Complete Care
Plan Number H5992-008
Service Area Bronx, Kings, Nassau, New York, Queens, Westchester
Plan Type D-SNP (QMB+, SLMB+, FBDE)
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $0
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $0
Prescription Deductible $0
Supplemental Benefits Fitness, Vision, OTC Allowance, Flex Card* (Food & Produce)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
45 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Ohio Lake
Lucas
Williams Fulton
Ottawa
Geauga
Cuyahoga
Defiance Henry Wood Sandusky Erie
Trumbull
Lorain
Service Area Paulding Huron
Medina Summit
Portage
Putnam Mahoning
2021 Existing Counties Van Wert
Wyandot Crawford
Ashland
Stark
Allen Richland Columbiana
2022 Expansion Counties
Hardin
2022 Aquisition Counties Mercer Auglaize Marion
Morrow
Holmes
Carroll
Jefferson
Logan Knox
Shelby Union
Delaware Coshocton Harrison
Darke
Champaign
Miami Licking Guernsey
Muskingum
Franklin
Clark
Madison
ry
Preble me
ntgo Fairfield Perry
Noble
Monroe
Mo Greene
Pickaway
Morgan
Fayette
Hocking
Washington
2022 Product Offerings:
Butler Warren Clinton
Athens
Vinton
Hamilton
• 1 D-SNP Highland
Pike Meigs
Clermont
Jackson
• 1 MAPD
Brown
Adams Gallia
Scioto
Lawrence
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
46 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.Ohio – Plan Information
Plan Marketing Name Molina Medicare Complete Care
Plan Number H9955-001
Adams, Auglaize, Brown, Butler, Carroll, Champaign, Clark, Clermont, Clinton, Columbiana, Coshocton,
Crawford, Cuyahoga, Darke, Defiance, Delaware, Erie, Fairfield, Fayette, Franklin, Fulton, Gallia, Geauga,
Greene, Guernsey, Hamilton, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Jackson, Lake, Lawrence,
Service Area Licking, Logan, Lorain, Lucas, Madison, Mahoning, Marion, Medina, Meigs, Mercer, Miami, Monroe,
Montgomery, Morgan, Morrow, Noble, Ottawa, Paulding, Perry, Pickaway, Pike, Portage, Preble, Putnam,
Shelby, Stark, Summit, Trumbull, Union, Van Wert, Vinton, Warren, Washington, Williams, Wood, Wyandot,
Allen, Ashland, Athens, Huron, Jefferson, Knox, Muskingum, Richland, Sandusky, Scioto
Plan Type D-SNP (All Dual)
Premium TBD
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance Original Medicare Cost Share
PCP Copay/Coinsurance 20%
Specialist Copay/Coinsurance 20%
Prescription Deductible $480 (Medicare defined)
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
Plans with 20% Cost Share for Medicare-Covered Benefits – Costs may be as low as $0, depending Medicaid eligibility
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
47 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.NEW
Ohio – Plan Information
Plan Marketing Name Molina Medicare Choice Care
Plan Number H9955-002
Adams, Allen, Ashland, Athens, Auglaize, Brown, Butler, Carroll, Champaign, Clark, Clermont, Clinton,
Columbiana, Coshocton, Crawford, Cuyahoga, Darke, Defiance, Delaware, Erie, Fairfield, Fayette, Franklin,
Fulton, Gallia, Geauga, Greene, Guernsey, Hamilton, Hardin, Harrison, Henry, Highland, Hocking, Holmes,
Service Area Huron, Jackson, Jefferson, Knox, Lake, Lawrence, Licking, Logan, Lorain, Lucas, Madison, Mahoning, Marion,
Medina, Meigs, Mercer, Miami, Monroe, Montgomery, Morgan, Morrow, Muskingum, Noble, Ottawa, Paulding,
Perry, Pickaway, Pike, Portage, Preble, Putnam, Richland, Sandusky, Scioto, Shelby, Stark, Summit, Trumbull,
Union, Van Wert, Vinton, Warren, Washington, Williams, Wood, Wyandot
Plan Type MAPD
Premium $0
Maximum Out of Pocket $7,550
Inpatient Copay/Coinsurance $295/day (Days 1-6) $0/day (Days 7-90)
PCP Copay/Coinsurance $0
Specialist Copay/Coinsurance $30
Prescription Deductible $125
Hearing, Meals, Fitness, Flex Card (Dental, Vision, Transportation, OTC Allowance), Flex Card*
Supplemental Benefits (Food & Produce, Service Animal Supplies, Pest Control, Mental Health & Wellness Applications,
Non-Medicare-Covered Genetic Test Kit)
*Members with certain chronic conditions. For existing plans, blue indicates a new benefit or service area for 2022.
This document is not intended for marketing purposes or public distribution and is considered “Confidential Information”, as defined in your Agreement with
48 Molina Healthcare, Inc. (“MHI”). Distribution and reproduction of this document is strictly prohibited and may be grounds for immediate termination of your
Agreement and any other legal remedies MHI may have . The information in this document is pending CMS approval and may be subject to change.You can also read
