What Does Molina Healthcare Cover in Washington?

Molina Healthcare’s Washington Apple Health (Medicaid) plan covers a full set of medical, behavioral health, pharmacy, maternity, and preventive services at no cost to members, as long as the care is medically necessary. The plan also layers on extras Apple Health doesn’t require, such as free eyeglasses for adults and a cash-rewards program for completing preventive visits. A handful of services are either excluded or carved out to Apple Health’s fee-for-service program, which you access with your ProviderOne card instead of your Molina card.

Doctor Visits, Hospital Care, and Emergencies

Primary care visits, specialist appointments, and inpatient hospital stays are all covered. Emergency room care is fully covered for both physical and behavioral health emergencies, inside or outside Molina’s service area.¹ Lab work, X-rays, MRIs, CT scans, and other imaging are covered benefits.² Ambulance transport is covered in emergencies, including mental health crises, and non-emergency ambulance rides are available when you need a stretcher or medical monitoring. Many services require prior authorization from Molina before they are provided.

If you’re outside Washington, Molina still covers urgent and medically necessary care that can’t wait until you get home. For routine care, you need to be inside the service area.

Virtual Urgent Care

Every Molina Apple Health member has free, 24/7 access to Teladoc for virtual urgent care, with no appointment needed. Doctors or nurse practitioners typically connect within 30 minutes by phone, app, or web, and they can prescribe medication and send follow-up notes to your regular provider.³ Teladoc handles minor conditions such as colds, flu, allergies, sore throats, sinus problems, rashes, pink eye, and minor burns.⁴ Your own providers may also offer telehealth appointments.

Prescription Drugs

Molina covers prescriptions that are medically necessary, ordered by a contracted provider, and listed on the plan’s formulary, which follows the Washington Health Care Authority’s Preferred Drug List and includes at least one drug per therapeutic category.⁵ Generics are the default; a brand name when a generic exists requires prior authorization.⁶ Prior authorization is also needed when a drug is flagged “PA” on the formulary, when the drug isn’t on the formulary, when the quantity exceeds limits, or when a refill is requested too early.

Some categories are excluded outright: drugs for weight loss, erectile dysfunction, infertility, and cosmetic purposes.⁷ Outside Washington, prescriptions are only covered in emergencies or urgent situations, and the pharmacy can dispense up to a 72-hour supply.⁶ If a request is denied, you can appeal.

Mental Health and Substance Use Treatment

You don’t need a referral for behavioral health care. You can self-refer for an initial evaluation and ongoing outpatient services.⁸

Covered mental health services include evaluations, individual, group, and family therapy, medication management, psychological testing, peer support, and Applied Behavior Analysis for autism. Higher-intensity care is covered too: crisis stabilization, acute psychiatric inpatient admission, the Program of Assertive Community Treatment, Wraparound with Intensive Services for youth, and intensive residential treatment.

For substance use disorders, Molina covers evaluations, individual and group counseling, family therapy, peer support, case management, intensive outpatient programs, opioid use disorder treatment with medication and therapy, withdrawal management, and residential treatment at multiple intensity levels. Emergency behavioral health services, including mobile crisis response, crisis stabilization units, and withdrawal management, do not require prior authorization and are covered whether the provider is in network or not.⁹

Crisis lines available to members: the 988 Suicide and Crisis Lifeline, the Washington Recovery Help Line at (866) 789-1511, and Washington Crisis Connections at (866) 427-4747.¹⁰

Pregnancy, Postpartum, and Birth Control

Prenatal visits across all trimesters, labor and delivery (at a hospital, birthing center, or home), and postpartum check-ups between 7 and 84 days after delivery are all covered. The postpartum visit includes depression and anxiety screening and a birth control discussion.¹¹

Qualifying pregnant members can get a free electric breast pump through Aeroflow, free prenatal vitamins, and a referral to WIC.¹² Ouma Health gives members 24/7 video-chat access to maternity providers at no cost, and members with high-risk pregnancies can get specialized support through Molina’s Health and Wellness team.

All FDA-approved contraceptive drugs, devices, and supplies are covered, including over-the-counter options, with no quantity limits and no prior authorization. Pharmacies can dispense up to a 12-month supply at once.¹ Voluntary termination of pregnancy is covered through Apple Health’s fee-for-service program rather than through Molina, and birth doula services and childbirth classes are also fee-for-service.

Preventive Care and Services for Kids

Molina covers immunizations on the CDC schedule for children and adults, well-child visits, breast cancer screenings, cervical cancer screenings, and chlamydia testing.¹³ Annual depression screenings are required for youth ages 12 through 18, and depression screenings are covered for mothers and caregivers of infants up to six months old.

Members age 20 and younger get Early and Periodic Screening, Diagnosis and Treatment (EPSDT), which covers comprehensive screenings for vision, dental, hearing, developmental milestones, and autism, plus treatment for anything identified. Under EPSDT, a child may still receive a service that would otherwise be excluded if it’s medically necessary.

Dental, Vision, and Hearing

Dental and vision work differently from most other benefits because some pieces come through Molina and others come straight from Apple Health fee-for-service.

Dental

Molina does not provide dental care. Most dental services for children, adults, pregnant members, and some adults with disabilities are covered by the Health Care Authority through fee-for-service, billed with your ProviderOne card.¹⁴ The Access to Baby and Child Dentistry program covers children ages 0–5 and children ages 6–12 with a disability. Orthodontic braces are not covered under the managed care plan.²

Vision

Routine eye exams and vision therapy are covered through Molina, though the eye exam benefit is described as limited. Eyeglasses for members age 20 and younger come through fee-for-service, not Molina. For adults 21 and older, Molina offers free eyeglasses as a value-added benefit through Zenni Eyewear, with over 55 styles including bifocal and progressive lenses.¹²

Hearing

Hearing exams, hearing aids, and cochlear implants are all covered. Bone-anchored hearing aids are covered for members age 20 and younger.

Rehab Therapies, Equipment, and Rides

Physical, occupational, and speech therapy are covered as limited benefits, which means there may be caps on visits. Massage is covered only as part of a PT or OT treatment plan. Neurodevelopmental therapy, cardiac rehabilitation, and habilitative services for adults are covered. Pulmonary rehabilitation is not.¹⁵

Durable medical equipment is covered when medically necessary: wheelchairs, hospital beds, respiratory equipment, orthotics and prosthetics, breast pumps, and incontinence supplies for members over age three. Non-medical home modifications such as ramps are excluded. Glucometer test strips come through the pharmacy benefit, not DME.

Emergency and non-emergency medical transportation are both covered for medical and behavioral health appointments. For non-emergency rides you arrange ahead through a local transportation broker, and prior authorization is required.¹⁶ If you drive yourself, you may be eligible for gas reimbursement.

Children age 17 and younger with complex medical needs (such as ventilator dependence or tracheostomy care) may qualify for in-home skilled nursing through the Medically Intensive Children’s Program, which requires at least four continuous hours of skilled nursing per day.¹⁷

Gender-Affirming Care

Molina covers treatment for gender dysphoria, including primary care, hormone therapy, behavioral health services, and counseling.¹⁸ Surgical procedures may be considered medically necessary for members age 18 and older who meet Molina’s clinical criteria, which include a documented diagnosis of gender dysphoria lasting at least six months and stable mental and physical health. Covered procedures range from mastectomy and chest reconstruction to vaginoplasty and phalloplasty, with their own referral-letter requirements.¹⁹ Most surgical services and hair removal go through fee-for-service with prior authorization from the Health Care Authority rather than through Molina. LGBTQIA+ health care navigators at Molina can help confirm specific benefits.

Extras Molina Adds On Top

Beyond the required Apple Health benefits, Molina offers several value-added perks:

Free eyeglasses for adults 21 and older through Zenni Eyewear.
Free annual Boys and Girls Club membership for members ages 6–18.
Up to 28 chef-prepared, medically tailored meals from Mom’s Meals after a hospital discharge.
A free wireless plan through TruConnect with 4 GB of data, unlimited talk and text, and free international calls to several countries.
Discounted Amazon Prime membership.
Online substance use disorder treatment through Boulder Care and Bicycle Health, plus the Pyx Health app for mental health support.
Wellness coaching from health coaches, nurses, and registered dietitians, including diabetes and bariatric care programs.
Molina Help Finder for housing, job training, education, and food resources, and Community Connectors for members leaving jail or detention.

Molina also runs a rewards program paying up to $200 every 12 months for completing preventive activities, loaded onto a reloadable card usable at participating retailers, for gas, or for bill payments. Examples: $50–$100 for prenatal and postpartum visits, $100 for a breast cancer screening, $50 for a cervical cancer screening, $25–$75 for well-child visits depending on age, and $50 for childhood immunization groups.²⁰

Voluntary case management is available at no cost by self-referral or provider referral, with case managers who help with scheduling, transportation, care coordination among providers, and community resources.²¹ A 24/7 nurse advice line is available for health questions.²²

Services Carved Out to Fee-for-Service

Some services are covered under Apple Health but not through Molina. You use your ProviderOne card for these:

Most dental care
Eyeglass frames and lenses for members under 21
Voluntary termination of pregnancy
Birth doula services and childbirth classes
Most gender-affirming surgeries and hair removal
Adult chiropractic care
Orthodontic braces (when covered at all)

If a service is denied, you or your provider can appeal.¹

Services Not Covered at All

Several services are excluded under any Apple Health benefit:

Acupuncture
Cosmetic surgery, unless it’s reconstructive surgery to correct a defect from trauma, a birth defect, or illness
Non-medical home modifications such as ramps
Infertility testing and treatment, including donor egg or sperm services and reversal of sterilization
Services received outside the United States and its territories, with a narrow exception for emergent and routine care in British Columbia
Tomographic colonography for routine colorectal cancer screening

Getting Help and Prior Authorization

Call Molina Member Services at (800) 869-7165 (TTY 711), Monday through Friday, 7:30 a.m. to 6:30 p.m., for questions about coverage, finding a provider, or prior authorization. The nurse advice line is open 24/7. Molina’s website hosts the provider directory, formulary search tool, and prior authorization code lookup.²³

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Molina Healthcare. IMC Benefits Index
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Molina Healthcare. Benefits at a Glance
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Molina Healthcare. Virtual Urgent Care
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Molina Healthcare. Virtual Urgent Care
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Molina Healthcare. Pharmacy Services
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Molina Healthcare. Prescription Drugs
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Molina Healthcare. Formulary
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Molina Healthcare. Behavioral Health
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Molina Marketplace. Disorder Treatment Information
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Molina Healthcare. BHSO Behavioral Health
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Molina Healthcare. Pregnancy Care
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Molina Healthcare. Value Added Benefits
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Molina Healthcare. Preventive Care
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Molina Healthcare. Dental
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Molina Healthcare. Benefits at a Glance
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Molina Healthcare. Transportation
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Molina Marketplace. Private Duty Nursing Flyer
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Molina Healthcare. LGBTQIA+ Services and Gender-Affirming Care
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Molina Healthcare. Gender Affirmation Treatment and Procedures
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Molina Healthcare. Member Rewards
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Molina Healthcare. Case Management
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Molina Healthcare. Health Management
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Molina Healthcare. Covered Services