Health Incentives Molina Healthcare offers a variety of incentives to members. Our incentive program encourages members to make healthy choices. Members may receive reward points they can redeem online for health related items (up to $200 in total rewards per calendar year for Medicaid). In this packet are current Medicaid and Medicare incentive forms. Please complete the form, attach the member’s medical records and send to Molina for processing. You or the member may fax, mail or email. Please allow 3-4 weeks to process.   

Email Address: [email protected] Incentives Fax Line: (800) 461-3234 Wellness Quality Line: (888) 562-5442 Ext. 141428

Medicaid Health Incentives: Healthy 15-Month-Olds: A new baby must complete six well child exams by the time the child is 15 months old.

Healthy Two-Year-Olds: A new baby must complete all required immunizations before the child turns 2 years old.

Well Child Check Ups, Ages 3, 4, 5 and 6: A yearly well child check-up is a physical exam that includes vision and hearing tests, which may also include immunizations if they are due.

Adolescent Well Care, Ages 12-21: A yearly adolescent well care exam that includes a complete physical exam, vision and hearing tests. The provider should also check blood pressure, height, weight and body mass index (BMI). Teens may need some immunizations or boosters.

Breast Cancer Screening: Women who are 50 years to 74 years of age should get a mammogram every two years. Women who have had breast cancer or other breast problems, or have a family history of breast cancer, might need to get mammograms before age 50. They may also need to get them more often. The frequency of the mammogram should be decided at provider discretion and based on the member’s needs. To receive reward points in this program, the member should get a mammogram at least once every two years.

Prenatal Care: The member should see a provider in the first three months of pregnancy or within 42 days of joining Molina.

Postpartum Care: After delivery, the member should complete postpartum check-up within 21-56 days.

Staying Healthy with Diabetes: Please work with the members to set and reach their diabetes management goals. These are for members who should reduce their Hemoglobin A1C and get their annual eye exams to receive reward points.

Medicare Health Incentives: Breast Cancer Screening: Women who are 50 years to 74 years of age should get a mammogram every two years. Women who have had breast cancer or other breast problems, or have a family history of breast cancer, might need to get mammograms before age 50. They may also need to get them more often. The frequency of the mammogram should be decided at provider discretion, based on the member’s needs.

Colorectal Cancer Screening: Both men and women age 50-75 are recommended for colorectal screening. Please discuss with the member which test is appropriate for them. Remember not all tests should be done annually. Use provider discretion based on the member’s need.   

High-sensitivity fecal occult blood test (FOBT) Flexible sigmoidoscopy Colonoscopy

Annual Flu Vaccine: It is recommended everyone 6 months of age and older receive an annual vaccination. Members who receive their flu vaccination between September 1, 2016 and December 31, 2016 are eligible for this reward. Flu vaccines can be done at the provider office or local pharmacy, if available.

Diabetes Care: Please work with members to set and reach diabetes management goals. Members who receive a Hemoglobin A1c test and a Nephropathy Screening will receive reward points. Additionally, members that complete an annual diabetic eye exam will receive reward points.

*Health incentives are subject to change without notice*

Table of Contents Healthy 15-Month-Olds Healthy Two-Year-Olds Well Child Check Ups, Ages 3, 4, 5 and 6 Adolescent Well Care, Ages 12-21 Breast Cancer Screening Prenatal Packet     

Congrats Letter 1st Prenatal Visit Form Postpartum Visit Form More Services and Support Language Page

Postpartum Packet       

Congrats Letter Postpartum Visit Form Healthy 15 Month Old Form Healthy Two year old form (Immunization) Recommended Shots Pregnancy Rewards Survey Language Page

Staying Healthy with Diabetes  

Hemoglobin A1C Annual Eye Exams

Breast Cancer Screening (Medicare) Colorectal Cancer Screening (Medicare) Annual Flu Vaccine (Medicare) Diabetes Care (Medicare)

MRC Part #16-2131 Approvals: MHW—2/9/15

Well Child Check-Ups - Earn $40* in Gift Rewards Complete ALL well child check-ups and earn $40* in Gift Rewards Well child check-ups help keep your child healthy. A well child check-up is a physical exam. A blood lead test at age one (1) is also done. Your child will also get immunized (shots). You can talk with your child’s provider about any concerns you may have. All six (6) visits must be completed BEFORE your child is 15 months old to get one (1) $40* gift reward. Molina Healthcare can help. Call us today if you need help finding a provider for your child. For questions please call Molina Healthcare at (800) 869-7165.

Complete all well child checks BEFORE your child is 15 months old.

ALL

COMPLETE

Complete ALL Well Child Check-Ups Exams Needed 1st Visit 2nd Visit 3rd Visit 4th Visit 5th Visit 6th Visit

When to Complete Exam

Newborn-1 month old 2-3 months old 4-5 months old 6-8 months old 9-11 months old 12-14 months old

Date Completed

TO RECEIVE YOUR CHILD’S REWARD: • Please COMPLETE ENTIRE FORM • Have your Child’s Provider fax to Molina Healthcare (Include COPY OF MEDICAL RECORDS)

Child’s Name: _________________________________________ Child’s DOB: _________________________ Mailing Address: __________________________________________ Apt: _____________________________ City: ________________________________ State: __________ Zip Code: _________________________ Home Phone: _________________________ Cell Phone: _________________________________________ • Your child must be a Molina Healthcare of Washington member. • At least 6 well child check-ups need to be completed before your child is 15 months old. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please note: Each member is eligible for up to $200 of rewards per calendar year. Provider Use Only

MRC Part #14-1618 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Please fax completed form and copy of medical records related to these exams to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/ TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711).

Exámenes de bienestar infantil - reciba $40* en recompensas

Complete TODOS los exámenes de bienestar infantil y reciba $40* en regalos de recompensa. Los exámenes de bienestar infantil le ayudan a mantener a su niño saludable. Un examen de bienestar infantil es un examen físico. También se realiza un examen de plomo en la sangre cuando su niño cumple un (1) año de edad. Su niño también será inmunizado (vacunas). Puede hablar con el proveedor de su niño acerca de cualquier preocupación que tenga. Para recibir un (1) regalo de recompensa de $40* debe completar las seis (6) citas ANTES de que su niño cumpla 15 meses de edad. Molina Healthcare le puede ayudar. Llámenos hoy mismo si necesita ayuda para encontrar un proveedor para su niño. For questions please call Molina Healthcare at (800) 869-7165.

Complete todos los exámenes de bienestar infantil ANTES de que su niño cumpla 15 meses de edad. CUMPLA CON TODO

Complete TODOS los exámenes de bienestar infantil Exámenes necesarios 1.a consulta 2.a consulta 3.a consulta 4.a consulta 5.a consulta 6.a consulta

Cuándo obtener el examen Recién nacido - 1 mes de edad 2 a 3 meses de edad 4 a 5 meses de edad 6 a 8 meses de edad 9 a 11 meses de edad 12 a 14 meses de edad

Fecha que se realizó

PARA RECIBIR LA RECOMPENSA PARA SU NIÑO: • Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que el proveedor de su niño lo envíe por fax a Molina Healthcare (incluya una COPIA DE LA HISTORIA CLÍNICA).

Nombre del niño: _______________________________ Fecha de nacimiento del niño: ____________________ Dirección postal: __________________________________________

Apt.: ________________________

Ciudad: __________________________________ Estado: __________

Código postal: ___________________

Tel. del hogar: ___________________

Tel. celular: ________________________________

• Su niño debe ser miembro de Molina Healthcare of Washington. • Debe completar por lo menos 6 exámenes de bienestar infantil antes de que su niño cumpla 15 meses de edad. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. * Aviso: Cada miembro puede recibir hasta $ 200 en recompensas cada año. Please fax completed form and copy of medical records related to these exams to (800) 461-3234. Thank you. MRC Part #14-1618 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Provider Use Only (Sólo para el uso del proveedor)

Child Immunizations - Earn $40* in Gift Rewards Complete ALL needed shots before your child is 2 years old and earn $40* in Gift Rewards Children should get shots as soon as they are born. Shots help protect against disease. Talk with your provider about what shots your child will need. Get one (1) $40* gift reward for completing all shots child needs before they turn 2 years old. See immunization schedule for more details. Molina Healthcare can help. Call us today if you need help finding a provider for your child. For questions please call Molina Healthcare at (800) 869-7165.

Complete All

Complete all shots before your child is 2 years old: ☐ At least four (4) DTaP (Diphtheria,

☐ At least four (4) PCV (Pneumococcal

☐ One (1) MMR (Measles, Mumps and Rubella)

☐ One (1) VZV (Chicken pox)

☐ At least three (3) Hep B (Hepatitis B)

☐ At least three (3) IPV (Polio)

Tetanus and Acellular Pertussis)

Conjugate Vaccine)

☐ Three (3) HiB (H influenza type B)

TO RECEIVE YOUR CHILD’S REWARD:

• Please COMPLETE ENTIRE FORM • Have your Child’s Provider fax to Molina Healthcare (Include COPY OF IMMUNIZATION RECORDS) Child’s Name: ___________________________________________ Child’s DOB: __________________________ Mailing Address: __________________________________________ Apt: ________________________ City: __________________________________ State: __________ Zip Code: _________________________ Home Phone: ________________________ Cell Phone: _______________________________ • Your child must be a Molina Healthcare of Washington member. • All shots must be completed before your child is 2 years. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please note: Each member is eligible for up to $200 of rewards per calendar year. Provider Use Only Please fax completed form and copy of immunization record to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/ TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711). MRC Part #14-1617 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Vacunación para niños - reciba $40* en recompensas Complete TODAS las vacunas necesarias antes de que su niño cumpla 2 años de edad y reciba $40* en regalos de recompensas. Los niños deben recibir vacunas pronto después de nacer. Las vacunas ayudan a proteger contra enfermedades. Hable con su proveedor acerca de las vacunas que su niño necesita. Reciba un (1) regalo de recompensa de $40* cuando completa todas las vacunas que su niño necesita antes de cumplir 2 años de edad. Consulte el calendario de vacunación para obtener más detalles. Molina Healthcare le puede ayudar. Llámenos hoy mismo si necesita ayuda para encontrar un proveedor para su niño. Si usted tiene preguntas, por favor llame a Molina Healthcare al (800) 869-7165.

Cumpla con todo

Complete all shots before your child is 2 years old: ☐ Por lo menos (4) DTaP (difteria,

☐ Por lo menos cuatro (4) PCV (vacuna

☐ Una (1) MMR (sarampión, paperas y rubéola)

☐ Una (1) VZV (varicela)

☐ Por lo menos tres (3) Heb B (hepatitis B)

☐ Por lo menos tres (3) IPV (poliomielitis)

tétanos y tosferina acelular)

meningocócica conjugada)

☐ Tres (3) HiB (influenza H tipo B)

PARA RECIBIR LA RECOMPENSA PARA SU NIÑO:

• Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que el proveedor de su niño lo envíe por fax a Molina Healthcare (incluya una COPIA DEL REGISTRO DE VACUNAS). Nombre del niño: ______________________________________ Fecha de nacimiento del niño: _______________ Dirección postal: __________________________________________ Apt.: ________________________ Ciudad: __________________________________ Estado: _________ Código postal: ____________________ Tel. del hogar: ____________________________ Tel. celular: _________________________________________ • Su niño debe ser miembro de Molina Healthcare of Washington. • Todas las vacunas se deben recibir antes de que su niño cumpla 2 años de edad. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. * Aviso: Cada miembro puede recibir hasta $ 200 en recompensas cada año natural. Provider Use Only (Sólo para el uso del proveedor) Please fax completed form and copy of immunization record to (800) 461-3234. Thank you. MRC Part #14-1617 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Well Child Check-up at 3, 4, 5 and 6 years of age! You could be eligible to receive 300 points (a $30 value) in shopping rewards through our incentive program! Well child check-ups help keep your child healthy. A well child check-up is a physical exam. It also includes vision and hearing tests. Your child will also get immunized (shots) if they are due. Shots will help your child stay healthy. 1. Take your child in yearly for a well child check-up at 3, 4, 5 and 6 years of age 2. Molina Healthcare will give you 300 points (a $30 value) in on-line shopping rewards (free shipping) 3. You will receive a card in the mail telling you how to redeem your rewards. For questions or more information please call Member Services at (800) 869-7165. Member’s (Child) Name:

$30



Molina ID: Address:

Date of Birth Apt#:

City:

Zip Code:

Phone Number with Area Code: Provider: Please complete this section and fax to (800) 461-3234 along with a copy of the child’s medical record documenting the well child visit. Did this member receive a physical exam? Yes

No

Date of exam:______________

With chart please send copy of Health Education/Anticipatory guidance. Provider Name (please print):

Phone:

Provider Signature: For more information about Molina Healthcare, visit our website at www.MolinaHealthcare.com. * Please note: Each member is eligible for up to $200 of rewards per calendar year.

42431WA0614 MRC Part # 14-1565 Approvals: MHW - 7/8/14 HCA - 7/22/14

Adolescent Well Care Visit for Ages 12 to 21! You could be eligible to receive 300 points (a $30 value) in shopping rewards through our incentive program! Teens and young adults need to keep healthy too. Check-ups include a complete physical exam. It also includes vision and hearing tests. Your provider should check blood pressure, height, weight and body mass index (BMI). You may need some shots or boosters. Talk to your provider about any concerns you may have. 1. Take your adolescent in yearly for a well care check-up between the ages of 12-21

$30

2. Molina Healthcare will give you 300 points (a $30 value) in on-line shopping rewards (free shipping) 3. You will receive a card in the mail telling you how to redeem your rewards. For questions or more information please call Member Services at (800) 869-7165.

Member’s Name: Molina ID: Address:

Date of Birth Apt#:

City:

Zip Code:

Phone Number with Area Code:

Provider: Please complete this section and fax to (800) 461-3234 along with a copy of the medical record documenting the well care visit. Did this member receive a physical exam? Yes

No

Date of exam:__________

With chart please send copy of Health Education/Anticipatory guidance. Provider Name (please print):

Phone:

Provider Signature: For more information about Molina Healthcare, visit our website at www.MolinaHealthcare.com. * Please note: Each member is eligible for up to $200 of rewards per calendar year.

42430WA0614 MRC Part # 14-1565 Approvals: MHW - 7/8/14 HCA - 7/22/14

f l e s r u o Y d r a w e R and Your Health! Breast cancer screenings (mammograms) are a vital part of a woman’s health. Molina Healthcare wants you to be aware of the importance of getting a mammogram. Mammograms are the best screening tool used today to detect changes in the breast. It allows your provider to see changes in breast tissue that cannot be felt during a breast exam. The earlier changes in the breast are detected, the easier they are to treat. Our records show you may be due for your mammogram. Your Primary Care Provider (PCP) will tell you when you should start getting a mammogram, how often and if you fall into the high risk group. Please contact your PCP to see if you are due for a mammogram and to schedule an appointment.

As a thank you for getting this service, Molina Healthcare wants to give you a gift valued at $30! Have your provider complete the attached form and fax it to us at (800) 461-3234.

$30

In addition to getting a mammogram every 1-2 years, you should also see your women’s health provider for other important preventive health exams. If you have any questions, please call our Health Education line at (800) 423-9899 Ext. 141428. Molina Healthcare wants to support you in living a healthy life! * Please note: Each member is eligible for up to $200 of rewards per calendar year.

(Please fill out and keep the attached reminder for your next appointment.)

--------------------------------------------------------------------------------------------------------------------The appointment for my mammogram is: Date: _____________________________ Provider Name: ____________________________________ Time: _____________________________ Provider Number: __________________________________ Location: _______________________________________________________ MRC Part #13-1315 Approvals: MHW - 9/10/13 HCA - 11/12/13

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Breast Cancer Screening Complete the member section. Have your provider complete the provider section and fax this page back to Molina Healthcare to receive a gift valued at $30. Member: Please complete this part before giving to your provider.

Name: ____________________________________________________________________________________ Date of Birth: ______________________________________________________________________________ Address: __________________________________________________________________________________ City: ______________________________________________________Zip: ___________________________ Phone Number: ____________________________________________________________________________

Provider/Technologist: Please fill in below and fax back to Molina Healthcare at (800) 461-3234.

Date of Screening: __________________________________________________________________________ Provider Name (please print): _________________________________________________________________ Provider Phone: ____________________________________________________________________________ Provider Signature: __________________________________________________________________________

Dear Molina Member,

Congrats! Finding out that you are pregnant is special. Molina Healthcare is here to help you take care of you and your baby. You want to see your provider often. They can make sure that you and your baby are healthy. Plus, you can earn rewards for going to your provider visits.

Gifts and Rewards Just for You Reward

$40 gift value*

$40 gift value*

What you have to do If you were already with Molina Healthcare when you became pregnant you must go to your 1st prenatal visit within the first trimester. For newly enrolled members, you must go to your visit within 42 days of joining Molina Healthcare. Go to your postpartum visit within 21-56 days after you deliver (does not include visit to remove staples from a C-section).

How do I earn rewards? To earn rewards is easy. All you need to do is go to your provider visits. Fill out and send in the forms. Molina will send you your rewards. See forms for more details.

Total value in gifts - $80* If you have any questions about this program, call (800) 869-7165. They will be able to help you. This is a happy time for you and your family and Molina Healthcare is here to help. Sincerely, Molina Healthcare Your Extended Family

*Please note: Each member is eligible for up to $200 of rewards per calendar year. 42644WA1215 MRC Part #14-1608 Approvals: MHW - 8/12/14 HCA - 11/19/14

To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711).

Estimada miembro de Molina:

¡Felicidades! Es muy especial enterarse que está embarazada. Molina Healthcare está aquí para ayudarle a cuidar su salud y la de su bebé. Debe consultar con su proveedor a menudo. Su proveedor puede asegurar que usted y su bebé se mantengan saludable. Además, usted puede obtener recompensas cuando consulta con su proveedor.

¿Cómo obtengo recompensas?

Regalos y recompensas especialmente para usted

Es fácil obtener recompensas. Solamente tiene que asistir a sus citas con su proveedor.

Recompensa

Regalo de $40 en valor*

Regalo de $40 en valor*

Lo que tiene que hacer Si usted ya era miembro de Molina Healthcare cuando se embarazó debe asistir a su 1.a visita prenatal durante su primer trimestre. Las miembros recién inscritas, deben asistir a su consulta dentro de 42 días de haberse unido a Molina Healthcare. Asista a su consulta de posparto dentro de 21 a 56 días después del parto (no incluye la consulta para remover las grapas quirúrgicas de una cesárea).

Llene y envíe los formularios. Molina le enviará sus recompensas. Consulte los formularios para más información.

Regalos con un valor total de $80* Si usted tiene cualquier pregunta acerca de este programa, llame al (800) 869-7165. Le ofrecerán ayuda. Este es un tiempo feliz para usted y su familia. Molina Healthcare está aquí para ayudarle. Atentamente, Molina Healthcare Estás en familia.

42644WA1215 MRC Part #14-1608 Approvals: MHW - 8/12/14 HCA - 11/19/14

*Aviso: Cada miembro puede recibir hasta $200 en recompensas cada año.

1st Prenatal Visit – Earn $40* in Gift Rewards See Your Provider EARLY! Earn $40* in Gift Rewards If you are pregnant, see your provider right away. Early prenatal care will help keep you and your baby healthy. Even if you feel fine, you still need to be seen often. Molina Healthcare can help. Call us today if you need help finding a provider. For questions please call Molina Healthcare at (800) 869-7165. Complete your 1st prenatal visit within the first trimester or within 42 days of joining Molina Healthcare. TO RECEIVE YOUR REWARD: • Please COMPLETE ENTIRE FORM • Have your Provider fax to Molina Healthcare (Include COPY OF MEDICAL RECORDS) Member Name: ___________________________________________ DOB: ____________________________ Mailing Address: __________________________________________ Apt: ________________________ City: __________________________________ State: __________

Zip Code: _________________________

Home Phone: ________________________ Cell Phone: _______________________________ • You must be a Molina Healthcare of Washington member at the time service was given. • You must complete the service for this current pregnancy. Services done prior will not be accepted. • If you are already enrolled with Molina Healthcare of Washington when you become pregnant, you must complete a prenatal visit within the first trimester to receive your reward. If you are a newly enrolled member, you must complete a prenatal visit within 42 days of joining Molina Healthcare of Washington to receive your reward. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please note: Each member is eligible for up to $200 of rewards per calendar year. Tell us about your first prenatal visit First Exam Date: ____________________ Still Pregnant: ☐ YES ☐ NO Due Date: _________________________ Having twins/triplets: ☐ YES ☐ NO Weeks Pregnant: _________________________________________________ Provider Name: __________________________________________________ Clinic/Office Name: _______________________________________________ Provider Phone: __________________________________________________ Provider Signature:________________________________________________

How do you get to your provider visits? ☐ Bus or taxi ☐ Own car ☐ Molina transportation ☐ Ride from friend ☐ Other _______________

Provider Use Only Please fax completed form and copy of medical records related to this exam to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711). MRC Part #14-1610 Approvals: MHW - 8/12/14 HCA - 11/19/14

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1.a visita prenatal – Reciba un regalo de recompensa de $40* ¡Consulte con su proveedor TEMPRANO! Reciba un regalo de recompensa de $40* Si usted está embarazada, consulte con su proveedor inmediatamente. El cuidado prenatal en la etapa temprana del embarazo le ayudará a mantener a usted y a su bebé saludables. Aunque usted se sienta bien, necesita recibir atención a menudo. Molina Healthcare le puede ayudar. Llámenos hoy mismo si necesita ayuda para encontrar un proveedor. Si usted tiene preguntas, por favor llame a Molina Healthcare al (800) 869-7165.

Complete la 1.a visita prenatal durante el primer trimestre o dentro de 42 días de haberse inscrito con Molina Healthcare. PARA RECIBIR SU RECOMPENSA: • Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que su proveedor lo envíe por fax a Molina Healthcare (incluya una COPIA DE LA HISTORIA CLÍNICA).

Nombre del miembro: ____________________________________ Fecha de nacimiento: ___________________ Dirección postal: __________________________________________ Apt.: ________________________ Ciudad: __________________________________ Estado: ___________ Código postal: _________________ Tel. de hogar: ________________________ Tel. celular: _______________________________ • Debe ser un miembro de Molina Healthcare of Washington cuando reciba el servicio. • Debe completar el servicio durante este embarazo actual. Los servicios realizados anteriormente no se aceptarán. • Si usted ya estaba inscrita con Molina Healthcare of Washington cuando se embarazó, debe completar una visita prenatal durante su primer trimestre para recibir su recompensa. Si usted es un miembro recién inscrito, debe completar una consulta prenatal dentro de 42 días de haberse inscrito como miembro de Molina Healthcare of Washington para recibir su recompensa. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. *Aviso: Cada miembro puede recibir hasta $200 en recompensas cada año. Proporcione información acerca de su primera visita prenatal Fecha del primer examen: ________________ Aún está embarazada: ☐ SÍ ☐ NO Fecha de parto: _________________________ Tendrá gemelos / trillizos:☐ SÍ ☐ NO Semanas de embarazo:_____________________________________________ Nombre del proveedor: _____________________________________________ Nombre de la clínica / consultorio:_____________________________________

¿Qué tipo de transporte utiliza para ir a sus consultas? ☐ Autobús o taxi ☐ Carro personal ☐ Transporte de Molina ☐ Transporte con amigos ☐ Otro _______________

N.º de tel. del proveedor: ____________________________________________ Firma del proveedor:_______________________________________________ Provider Use Only (Sólo para el uso del proveedor) Please fax completed form and copy of medical records related to this exam to (800) 461-3234. Thank you. MRC Part #14-1610 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Postpartum Visit – Earn $40* in Gift Rewards Complete your postpartum checkup and earn $40* in Gift Rewards. After you have your baby, you still need to be seen by your provider. Even if you feel fine, you still need to be seen. Molina Healthcare can help. Call your provider to schedule an appointment. For questions please call Molina Healthcare at (800) 869-7165.

Complete your postpartum checkup 21-56 days after you deliver your baby. TO RECEIVE YOUR REWARD: • Please COMPLETE ENTIRE FORM • Have your Provider fax to Molina Healthcare (Include COPY OF MEDICAL RECORDS)

New Mom’s Name:___________________________________________ DOB: ______________ Mailing Address: ____________________________________________ Apt: ________________ City: ___________________________ State: ____________________ Zip Code: ______________ Home Phone: ___________________ Cell Phone: _____________________________ • You must be a Molina Healthcare of Washington member at the time service was given. • You must complete the service for this current pregnancy. Services done prior will not be accepted. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please Note: Each member is eligible for up to $200 of rewards per calendar year. Tell us about your postpartum visit Date of Delivery: ________________ Date of Postpartum Check Up: ____________________ ☐ Visit was within 21-56 days after delivery. Provider Name: ____________________________________________________________ Clinic/Office Name:__________________________________________________________ Provider Phone: ____________________________________________________________ Provider Signature: __________________________________________________________ Provider Use Only Please fax completed form and copy of medical records related to this exam to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/ TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711). MRC Part #14-1611 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Visita de posparto – Reciba un regalo de recompensa de $40* Complete su chequeo de posparto y reciba un regalo de recompensa de $40*. Después de dar a luz, aún necesita consultar con su proveedor. Aunque usted se sienta bien, necesita recibir atención. Molina Healthcare le puede ayudar. Comuníquese con su proveedor para programar una cita. Si usted tiene preguntas, por favor llame a Molina Healthcare al (800) 869-7165..

Complete su chequeo de posparto 21 a 56 días después del parto. PARA RECIBIR SU RECOMPENSA: • Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que su proveedor lo envíe por fax a Molina Healthcare (incluya una COPIA DE LA HISTORIA CLÍNICA).

Nombre de la mamá novata:____________________________________

Fecha de nacimiento: ______________

Dirección postal: ____________________________________________

Apt.: __________________________

Ciudad: _____________________________

Código postal: ____________________

Estado: __________

Tel. del hogar: ___________________________

Tel. celular: _________________________________

• Debe ser un miembro de Molina Healthcare of Washington cuando reciba el servicio. • Debe completar el servicio durante este embarazo actual. Los servicios realizados anteriormente no se aceptarán. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. *Aviso: Cada miembro puede recibir hasta $200 en recompensas cada año. Proporcione información acerca de su visita posparto Fecha del parto: __________________ Fecha del chequeo posparto: ____________________ ☐ La visita se realizó 21 a 56 días después del parto. Nombre del proveedor: _______________________________________________________ Nombre de la clínica / consultorio:_______________________________________________ N.º de tel. del proveedor: _____________________________________________________ Firma del proveedor: _________________________________________________________ Provider Use Only (Sólo para el uso del proveedor) Please fax completed form and copy of medical records related to this exam to (800) 461-3234. Thank you. MRC Part #14-1611 Approvals: MHW - 8/12/14 HCA - 11/19/14

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More Services and Support Molina Healthcare is here to help you. We are here every step of the way for you during your pregnancy. We offer programs to help you make healthy choices during and after your pregnancy.

Molina also offers health education programs to help you live a healthy life, during your pregnancy and beyond. These programs include:

®

• Motherhood Matters Program that helps pregnant women get the education and services they need for a healthy pregnancy.

®

• Healthy Living with Diabetes for members with diabetes.

®

Find out more about:

• Breathe with Ease for members with asthma.

Smoking Cessation Program. Contact Molina Healthcare. A team member will help you with the resources you need to quit smoking.

• Heart Healthy LivingSM for members with high blood pressure, heart failure or heart disease.

You can also call (800) QUIT-NOW.

• And much more…

24-Hour Toll Free Nurse Advice Line. The Molina Healthcare Nurse Advice Line is staffed around the clock. You can call seven days a week to talk to a nurse. We have nurses who speak many languages. English (888) 275-8750

TTY/711

To learn more about these and other programs through Molina, call (800) 869-7165.

Spanish (866) 648-3537 TTY/711

text4baby. As a member of Molina, you will be able to sign up for free text messages on prenatal care, baby health, raising your child and more. You can sign up by texting “BABY” to 511411 or go to text4baby.org. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711).

42645WA1215 MRC Part #14-1609 Approvals: MHW - 8/12/14 HCA - 11/19/14

Más servicios y apoyo Molina Healthcare está aquí para ayudarle. Estamos aquí a cada paso durante su embarazo. Ofrecemos programas para ayudarle a tomar decisiones saludables durante y después de su embarazo.

Molina también ofrece programas de educación para la salud para ayudarle a vivir una vida saludable durante su embarazo y en el futuro. Los programas incluyen:

Obtenga más información acerca de:

• Healthy Living with Diabetes® es para miembros que padecen de diabetes.

Programa para dejar de fumar. Comuníquese con Molina Healthcare. Un miembro de nuestro equipo le ayudará a obtener los recursos que usted necesita para ayudarle a dejar de fumar. También puede llamar a (800) QUIT-NOW. Línea de Consejos de Enfermeras las 24 horas. La Línea de Consejos de Enfermeras de Molina Healthcare está atendida las 24 horas al día. Puede llamar los siete días de la semana para hablar con una enfermera. Tenemos enfermeras que hablan muchos idiomas. Inglés (888) 275-8750 TTY/711 Español (888) 648-3537

TTY/711

text4baby. Como miembro de Molina, usted podrá inscribirse gratuitamente para recibir mensajes educativos en textos acerca de la atención prenatal, la salud de bebés, consejos para la crianza y más. Puede inscribirse enviando un mensaje de texto con la palabra "BEBE" al 511411 o visitando text4baby.org. 42645WA1215 MRC Part #14-1609 Approvals: MHW - 8/12/14 HCA - 11/19/14

• Motherhood Matters® es un programa que le ayuda a las mujeres embarazadas obtener la educación y los servicios que necesitan para un embarazo saludable.

• Breathe with Ease® es para miembros que padecen de asma. • Heart Healthy LivingSM es para miembros con tensión arterial alta, insuficiencia cardíaca o enfermedades del corazón. • y mucho más…

Para aprender más acerca de estos y otros programas de Molina, llame al (800) 869-7165.

Dear Molina Member,

Congrats! Having a new baby is special. It has been our pleasure to serve you during your pregnancy. We want you to work with your baby’s provider to keep your baby up-to-date with well child exams and shots. Taking your baby to his or her check-ups is key to helping him or her stay healthy.

Gifts and Rewards for You and Your New Baby Reward

What you have to do

$40 gift value*

Have your new baby complete all of his or her 6 well child visits before he or she is 15 months old.

$40 gift value*

Have your new baby complete all of his or her needed shots by the time he or she turns 2 years old.

How do I earn rewards? To earn rewards is easy. All you need to do is complete visits for you and your baby. Fill out and send in the forms. Molina will send you your rewards. See forms for more details.

Total value in gifts - $120* If you have questions about this program, call (800) 869-7165. We will be able to help you. This is a happy time for you and your family. Molina Healthcare is here to help. Sincerely, Molina Healthcare Your Extended Family To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/ TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711).

MRC Part #14-1614 Approvals: MHW - 8/12/14 HCA - 11/19/14 42650WA1215

*Please note: Each member is eligible for up to $200 of rewards per calendar year.

Estimada miembro de Molina:

¡Felicidades! Tener un recién nacido es muy especial. Ha sido un placer atenderla durante su embarazo. Queremos que colabore con el proveedor de su bebé para mantener a su bebé al día con los exámenes de bienestar y las vacunas. Es importante llevar a su bebé a sus chequeos para ayudar a mantenerlo saludable.

Regalos y recompensas para usted y su recién nacido Recompensa

Lo que tiene que hacer

Regalo de $40 en valor*

Asegúrese que su recién nacido reciba todas las 6 consultas de bienestar infantil antes de cumplir 15 meses de edad.

Regalo de $40 en valor*

Asegúrese que su recién nacido reciba todas las vacunas necesarias antes de cumplir 2 años de edad.

¿Cómo obtengo recompensas? Es fácil obtener recompensas. Solamente tiene que completar sus consultas y las de su bebé. Llene y envíe los formularios. Molina le enviará sus recompensas. Consulte los formularios para más información.

Regalos con un valor total de $120* Si usted tiene preguntas acerca de éste programa, llame al (800) 869-7165. Nosotros le podemos ayudar. Este es un tiempo feliz para usted y su familia. Molina Healthcare está aquí para ayudarle.

Atentamente, Molina Healthcare Estás en familia.

MRC Part #14-1614 Approvals: MHW - 8/12/14 HCA - 11/19/14 42650WA1215

*Aviso: Cada miembro puede recibir hasta $200 en recompensas cada año.

Postpartum Visit – Earn $40* in Gift Rewards Complete your postpartum checkup and earn $40* in Gift Rewards. After you have your baby, you still need to be seen by your provider. Even if you feel fine, you still need to be seen. Molina Healthcare can help. Call your provider to schedule an appointment. For questions please call Molina Healthcare at (800) 869-7165.

Complete your postpartum checkup 21-56 days after you deliver your baby. TO RECEIVE YOUR REWARD: • Please COMPLETE ENTIRE FORM • Have your Provider fax to Molina Healthcare (Include COPY OF MEDICAL RECORDS)

New Mom’s Name:___________________________________________ DOB: ______________ Mailing Address: ____________________________________________ Apt: ________________ City: ___________________________ State: ____________________ Zip Code: ______________ Home Phone: ___________________ Cell Phone: _____________________________ • You must be a Molina Healthcare of Washington member at the time service was given. • You must complete the service for this current pregnancy. Services done prior will not be accepted. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please Note: Each member is eligible for up to $200 of rewards per calendar year. Tell us about your postpartum visit Date of Delivery: ________________ Date of Postpartum Check Up: ____________________ ☐ Visit was within 21-56 days after delivery. Provider Name: ____________________________________________________________ Clinic/Office Name:__________________________________________________________ Provider Phone: ____________________________________________________________ Provider Signature: __________________________________________________________ Provider Use Only Please fax completed form and copy of medical records related to this exam to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/ TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711). MRC Part #14-1611 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Visita de posparto – Reciba un regalo de recompensa de $40* Complete su chequeo de posparto y reciba un regalo de recompensa de $40*. Después de dar a luz, aún necesita consultar con su proveedor. Aunque usted se sienta bien, necesita recibir atención. Molina Healthcare le puede ayudar. Comuníquese con su proveedor para programar una cita. Si usted tiene preguntas, por favor llame a Molina Healthcare al (800) 869-7165..

Complete su chequeo de posparto 21 a 56 días después del parto. PARA RECIBIR SU RECOMPENSA: • Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que su proveedor lo envíe por fax a Molina Healthcare (incluya una COPIA DE LA HISTORIA CLÍNICA).

Nombre de la mamá novata:____________________________________

Fecha de nacimiento: ______________

Dirección postal: ____________________________________________

Apt.: __________________________

Ciudad: _____________________________

Código postal: ____________________

Estado: __________

Tel. del hogar: ___________________________

Tel. celular: _________________________________

• Debe ser un miembro de Molina Healthcare of Washington cuando reciba el servicio. • Debe completar el servicio durante este embarazo actual. Los servicios realizados anteriormente no se aceptarán. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. *Aviso: Cada miembro puede recibir hasta $200 en recompensas cada año. Proporcione información acerca de su visita posparto Fecha del parto: __________________ Fecha del chequeo posparto: ____________________ ☐ La visita se realizó 21 a 56 días después del parto. Nombre del proveedor: _______________________________________________________ Nombre de la clínica / consultorio:_______________________________________________ N.º de tel. del proveedor: _____________________________________________________ Firma del proveedor: _________________________________________________________ Provider Use Only (Sólo para el uso del proveedor) Please fax completed form and copy of medical records related to this exam to (800) 461-3234. Thank you. MRC Part #14-1611 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Well Child Check-Ups - Earn $40* in Gift Rewards Complete ALL well child check-ups and earn $40* in Gift Rewards Well child check-ups help keep your child healthy. A well child check-up is a physical exam. A blood lead test at age one (1) is also done. Your child will also get immunized (shots). You can talk with your child’s provider about any concerns you may have. All six (6) visits must be completed BEFORE your child is 15 months old to get one (1) $40* gift reward. Molina Healthcare can help. Call us today if you need help finding a provider for your child. For questions please call Molina Healthcare at (800) 869-7165.

Complete all well child checks BEFORE your child is 15 months old.

ALL

COMPLETE

Complete ALL Well Child Check-Ups Exams Needed 1st Visit 2nd Visit 3rd Visit 4th Visit 5th Visit 6th Visit

When to Complete Exam

Newborn-1 month old 2-3 months old 4-5 months old 6-8 months old 9-11 months old 12-14 months old

Date Completed

TO RECEIVE YOUR CHILD’S REWARD: • Please COMPLETE ENTIRE FORM • Have your Child’s Provider fax to Molina Healthcare (Include COPY OF MEDICAL RECORDS)

Child’s Name: _________________________________________ Child’s DOB: _________________________ Mailing Address: __________________________________________ Apt: _____________________________ City: ________________________________ State: __________ Zip Code: _________________________ Home Phone: _________________________ Cell Phone: _________________________________________ • Your child must be a Molina Healthcare of Washington member. • At least 6 well child check-ups need to be completed before your child is 15 months old. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please note: Each member is eligible for up to $200 of rewards per calendar year. Provider Use Only

MRC Part #14-1618 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Please fax completed form and copy of medical records related to these exams to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/ TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711).

Exámenes de bienestar infantil - reciba $40* en recompensas

Complete TODOS los exámenes de bienestar infantil y reciba $40* en regalos de recompensa. Los exámenes de bienestar infantil le ayudan a mantener a su niño saludable. Un examen de bienestar infantil es un examen físico. También se realiza un examen de plomo en la sangre cuando su niño cumple un (1) año de edad. Su niño también será inmunizado (vacunas). Puede hablar con el proveedor de su niño acerca de cualquier preocupación que tenga. Para recibir un (1) regalo de recompensa de $40* debe completar las seis (6) citas ANTES de que su niño cumpla 15 meses de edad. Molina Healthcare le puede ayudar. Llámenos hoy mismo si necesita ayuda para encontrar un proveedor para su niño. For questions please call Molina Healthcare at (800) 869-7165.

Complete todos los exámenes de bienestar infantil ANTES de que su niño cumpla 15 meses de edad. CUMPLA CON TODO

Complete TODOS los exámenes de bienestar infantil Exámenes necesarios 1.a consulta 2.a consulta 3.a consulta 4.a consulta 5.a consulta 6.a consulta

Cuándo obtener el examen Recién nacido - 1 mes de edad 2 a 3 meses de edad 4 a 5 meses de edad 6 a 8 meses de edad 9 a 11 meses de edad 12 a 14 meses de edad

Fecha que se realizó

PARA RECIBIR LA RECOMPENSA PARA SU NIÑO: • Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que el proveedor de su niño lo envíe por fax a Molina Healthcare (incluya una COPIA DE LA HISTORIA CLÍNICA).

Nombre del niño: _______________________________ Fecha de nacimiento del niño: ____________________ Dirección postal: __________________________________________

Apt.: ________________________

Ciudad: __________________________________ Estado: __________

Código postal: ___________________

Tel. del hogar: ___________________

Tel. celular: ________________________________

• Su niño debe ser miembro de Molina Healthcare of Washington. • Debe completar por lo menos 6 exámenes de bienestar infantil antes de que su niño cumpla 15 meses de edad. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. * Aviso: Cada miembro puede recibir hasta $ 200 en recompensas cada año. Please fax completed form and copy of medical records related to these exams to (800) 461-3234. Thank you. MRC Part #14-1618 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Provider Use Only (Sólo para el uso del proveedor)

Child Immunizations - Earn $40* in Gift Rewards Complete ALL needed shots before your child is 2 years old and earn $40* in Gift Rewards Children should get shots as soon as they are born. Shots help protect against disease. Talk with your provider about what shots your child will need. Get one (1) $40* gift reward for completing all shots child needs before they turn 2 years old. See immunization schedule for more details. Molina Healthcare can help. Call us today if you need help finding a provider for your child. For questions please call Molina Healthcare at (800) 869-7165.

Complete All

Complete all shots before your child is 2 years old: ☐ At least four (4) DTaP (Diphtheria,

☐ At least four (4) PCV (Pneumococcal

☐ One (1) MMR (Measles, Mumps and Rubella)

☐ One (1) VZV (Chicken pox)

☐ At least three (3) Hep B (Hepatitis B)

☐ At least three (3) IPV (Polio)

Tetanus and Acellular Pertussis)

Conjugate Vaccine)

☐ Three (3) HiB (H influenza type B)

TO RECEIVE YOUR CHILD’S REWARD:

• Please COMPLETE ENTIRE FORM • Have your Child’s Provider fax to Molina Healthcare (Include COPY OF IMMUNIZATION RECORDS) Child’s Name: ___________________________________________ Child’s DOB: __________________________ Mailing Address: __________________________________________ Apt: ________________________ City: __________________________________ State: __________ Zip Code: _________________________ Home Phone: ________________________ Cell Phone: _______________________________ • Your child must be a Molina Healthcare of Washington member. • All shots must be completed before your child is 2 years. • All services are confirmed through claims data or medical records. Please allow 2-4 weeks after services have been confirmed to receive your rewards notice. *Please note: Each member is eligible for up to $200 of rewards per calendar year. Provider Use Only Please fax completed form and copy of immunization record to (800) 461-3234. Thank you. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/ TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711). MRC Part #14-1617 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Vacunación para niños - reciba $40* en recompensas Complete TODAS las vacunas necesarias antes de que su niño cumpla 2 años de edad y reciba $40* en regalos de recompensas. Los niños deben recibir vacunas pronto después de nacer. Las vacunas ayudan a proteger contra enfermedades. Hable con su proveedor acerca de las vacunas que su niño necesita. Reciba un (1) regalo de recompensa de $40* cuando completa todas las vacunas que su niño necesita antes de cumplir 2 años de edad. Consulte el calendario de vacunación para obtener más detalles. Molina Healthcare le puede ayudar. Llámenos hoy mismo si necesita ayuda para encontrar un proveedor para su niño. Si usted tiene preguntas, por favor llame a Molina Healthcare al (800) 869-7165.

Cumpla con todo

Complete all shots before your child is 2 years old: ☐ Por lo menos (4) DTaP (difteria,

☐ Por lo menos cuatro (4) PCV (vacuna

☐ Una (1) MMR (sarampión, paperas y rubéola)

☐ Una (1) VZV (varicela)

☐ Por lo menos tres (3) Heb B (hepatitis B)

☐ Por lo menos tres (3) IPV (poliomielitis)

tétanos y tosferina acelular)

meningocócica conjugada)

☐ Tres (3) HiB (influenza H tipo B)

PARA RECIBIR LA RECOMPENSA PARA SU NIÑO:

• Por favor, LLENE ESTE FORMULARIO COMPLETAMENTE. • Pida que el proveedor de su niño lo envíe por fax a Molina Healthcare (incluya una COPIA DEL REGISTRO DE VACUNAS). Nombre del niño: ______________________________________ Fecha de nacimiento del niño: _______________ Dirección postal: __________________________________________ Apt.: ________________________ Ciudad: __________________________________ Estado: _________ Código postal: ____________________ Tel. del hogar: ____________________________ Tel. celular: _________________________________________ • Su niño debe ser miembro de Molina Healthcare of Washington. • Todas las vacunas se deben recibir antes de que su niño cumpla 2 años de edad. • Todos los servicios serán confirmados a través de los datos de facturación o historia clínica. Por favor, permita 2 a 4 semanas después de confirmar los servicios para recibir su notificación de la recompensa. * Aviso: Cada miembro puede recibir hasta $ 200 en recompensas cada año natural. Provider Use Only (Sólo para el uso del proveedor) Please fax completed form and copy of immunization record to (800) 461-3234. Thank you. MRC Part #14-1617 Approvals: MHW - 8/12/14 HCA - 11/19/14

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Recommended Shots for Children from Birth through 18 Months Old Birth HepB

✓

1 Month

2 Months

4 Months

6 Months

12 Months

✓

15 Months

18 Months

✓

RV

✓

✓

✓

DTaP

✓

✓

✓

Hib

✓

✓

✓

✓

PCV

✓

✓

✓

✓

IPV

✓

✓

✓

✓

Influenza (Yearly)

✓

MMR

✓

Varicella

✓ ✓

HepA Shaded boxes show the shot can be given during shown age range NOTE: If your child misses a shot, you don’t need to start over. Just go back to your child’s provider for the next shot. Talk with your child’s provider if you have questions about shots. Always talk to your child’s provider about additional shots that they may need. To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711).

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Las vacunas recomendadas para niños, desde nacimiento y hasta los 18 meses de edad

Recién nacido HepB

✓

1 mes

2 meses

4 meses

6 meses

12 meses

✓

15 meses ✓

RV

✓

✓

✓

DTaP

✓

✓

✓

Hib

✓

✓

✓

✓

PCV

✓

✓

✓

✓

IPV

✓

✓

✓

✓

Gripe (cada año)

✓

MMR

✓

Varicela

✓

HepA Los cuadros sombreados muestran que la vacuna se puede administrar durante las edades indicadas. AVISO: si su niño no recibe una vacuna, no es necesario comenzar de nuevo. Sólo tiene que regresar a consultar con el proveedor de su niño para recibir las siguientes vacunas. Hable con el proveedor de su niño si tiene preguntas acerca de las vacunas. Siempre hable con su proveedor acerca de las vacunas adicionales que podrían ser necesarias. 42653WA1215

18 meses

✓

Pregnancy Rewards Survey Thank you for taking the time to see your provider during your pregnancy and earning pregnancy rewards. You can help us make pregnancy rewards better. Please take a few minutes to fill out this survey. You do not need to give us your name. Answer each question by checking your answer. We also welcome any extra comments. Please send it back in the enclosed envelope. Thank you for your time!

1. What is your age? ☐ Under 18 ☐ 26-34

☐ 18-25 ☐ 35 and Over

2. What county and state do you live in? ___________________ ___________________ County State 3. Was your pregnancy high risk? ☐ Yes

☐ No

☐ Not at all helpful ☐ Not very helpful ☐ Somewhat helpful ☐ Very helpful 7. How much did the pregnancy rewards motivate you to complete your provider visits on time? ☐ Not at all helpful ☐ Somewhat helpful

☐ Not very helpful ☐ Very helpful

8. Did you like the choices of gifts? ☐ Yes ☐ No Other gift ideas you would like to see ____________________________________

4. How did you hear about the pregnancy rewards? ☐ From my provider ☐ Molina called me ☐ From a friend ☐ Enrolled in program before ☐ Other _____________________ 5. When did you begin earning pregnancy rewards? ☐ 1st trimester ☐ 3rd trimester

6. How helpful were the pregnancy rewards materials in educating you about why and when you should see your provider during your pregnancy?

☐ 2nd trimester ☐ After I gave birth

9. Overall, how satisfied were you with the pregnancy rewards? ☐ Very dissatisfied ☐ Satisfied

☐ Dissatisfied ☐ Very Satisfied

10. How likely would you tell a friend about Molina’s pregnancy rewards? ☐ Not very likely ☐ Likely

☐ Not likely ☐ Very likely

Other comments:

_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ To get this information in other languages and accessible formats, please call Member Services at (800) 869-7165 (TTY/TDD: 711). Si necesita esta información en otros idiomas o en un formato accesible, por favor comuníquese con el Departamento de Servicios para Miembros al (800) 869-7165 (TTY/TDD: 711). Để nhận thông tin này bằng các ngôn ngữ khác và các định dạng cho người khuyết tật, xin vui lòng gọi Dịch vụ Thành viên theo số (800) 869-7165 (TTY/TDD: 711). Чтобы получить эту информацию на других языках и в других доступных форматах, обратитесь в Службу поддержки участников по тел. (800) 869-7165 (TTY/TDD: 711). 42654WA1215 MRC Part #14-1616 Approvals: MHW - 8/12/14 HCA - 11/19/14

Encuesta de recompensas del embarazo Muchas gracias por tomar el tiempo para consultar con su proveedor durante su embarazo y obtener las recompensas del embarazo. Usted nos puede ayudar a mejorar las recompensas del embarazo. Por favor tome unos cuantos minutos para llenar esta encuesta. No es necesario darnos su nombre. Conteste cada pregunta marcando su respuesta. También le agradecemos sus comentarios adicionales. Regrésela usando el sobre adjunto. ¡Gracias por su atención! 1. ¿Cuántos años tiene? ☐ menos de 18 ☐ 26-34

☐ 18-25 ☐ mayor de 35

2. ¿En qué condado y estado vive? ___________________ ___________________ Condado Estado 3. ¿Su embarazo fue de alto riesgo? ☐ Sí

☐ No

4. ¿Cómo se enteró del programa de recompensas del embarazo? ☐ Mi proveedor ☐ Molina me llamó ☐ Una amistad ☐ Estuve inscrita en el programa antes ☐ Otro _____________________ 5. ¿Cuándo comenzó a recibir las recompensas del embarazo? ☐ 1.ertrimester ☐ 3.er trimester

☐ 2.do trimester ☐ Después del parto

6. ¿Fueron útiles los materiales de recompensas del embarazo para informarle la razón y cuándo debería de consultar con su proveedor durante su embarazo? ☐ No útiles en absoluto ☐ No muy útiles ☐ Un poco útiles ☐ Muy útiles 7. ¿Cuánto la motivó las recompensas del embarazo para completar a tiempo sus consultas con el proveedor? ☐ No útil en absoluto ☐ No muy útil ☐ Un poco útil ☐ Muy útil 8. ¿Le gustó la selección de regalos? ☐ Sí ☐ No Comparta sus ideas para otros regalos que le gustarían ____________________________________ 9. ¿En general, como califica su satisfacción con las recompensas del embarazo? ☐ Muy insatisfecha ☐ Satisfecha

☐ Insatisfecha ☐ Muy satisfecha

10. ¿Cuál es la probabilidad que usted recomendará el programa de recompensas del embarazo de Molina a una amiga? ☐ No muy probable ☐ Probable

☐ No probable ☐ Muy probable

Otros comentarios:

_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 42654WA1215 MRC Part #14-1616 Approvals: MHW - 8/12/14 HCA - 11/19/14

Diabetes A1c $20 Gift Reward Offer It is important to Molina Healthcare that our members are healthy. One way to stay healthy is with regular visits to your provider to treat your diabetes. As your health partner, we know that you want to do everything you can to live a full and healthy life. That is why Molina is excited to offer you a gift reward. Team up with your provider to set and reach an A1c goal to eight or below. Once you reach that goal, Molina will send you a $20 gift reward. Fill out your name and address below and have your provider fax it back to Molina along with a copy of your medical record. You will receive a card in the mail telling you how to get your rewards.

Molina Healthcare Member

Molina Healthcare Provider

Name: Provider Signature: Provider Name (Please print or stamp):

Member ID#: Date of Birth: Mailing Address:

Clinic Name: Phone:

Apt #: City:

Zipcode:

MUST INCLUDE MEDICAL RECORD DOCUMENTATION WITH FLYER TO RECEIVE GIFT REWARD

Phone #:

Mail or fax the completed form to: Mail: Molina Healthcare of Washington Attn: Quality Health Education PO Box 4004 Bothell, WA 98041

Fax:

Attn: Quality Health Education (800) 461-3234

MolinaHealthcare.com

If you need help finding a provider, please call (800) 869-7165 (TTY 711) You will receive your gift reward within 4 to 6 weeks after processing and verification. Please note: Each member is eligible for up to $200 of rewards per calendar year. 2650940WA0715

Staying healthy with Diabetes

Dear Molina Healthcare Member: It is important to Molina that our members are healthy. One way to be and stay healthy is with regular visits to your provider’s office for treating and caring for your diabetes. As your health partner, we know that you want to do everything you can to live a full and healthy life. That’s why Molina is excited to bring to our diabetic members the Staying Healthy with Diabetes Rewards Program. As a member of this program, you can team up with your health care provider to set and reach your diabetes management goals. Once you reach your goal, you will have earned shopping rewards as explained below. Goals to reach (in any order): • Lower your present A1C to below 8 • Get an annual diabetes eye exam Rewards: • Members who reduce their A1C level to below 8 will receive 200 points (a $20 value) in shopping rewards • Members who receive their annual diabetes eye exam will receive 500 points (a $50 value) in shopping rewards Please call Member Services at (800) 869-7165 (TTY/TDD 711) if you need help or do not have access to the internet. Sincerely, Quality Improvement Molina Healthcare of Washington Your Extended Family! * Please note: Each member is eligible for up to $200 of rewards per calendar year.

MRC Part #16-2130 Approvals: MHW- 2/9/16 HCA-11/12/13 3641557WA0216

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Diabetes Eye Exam $50 Gift Reward Offer Do you have diabetes? Has it been over a year since your last eye exam? If you answered yes to these questions you may qualify for a $50 gift reward! If you have diabetes, you are at a greater risk for blindness even though your vision may seem fine. Only a dilated eye exam by an eye doctor can find the changes in your eyes that could lead to blindness. Early treatment of diabetic eye disease can prevent blindness. Contact your eye care provider or ask your regular provider for a referral. Fill out your name and address below and have your provider fax it back to Molina along with a copy of your eye exam record. You will receive a card in the mail telling you how to get your reward.

Molina Healthcare Member

Molina Healthcare Provider

Name: Provider Signature: Provider Name (Please print or stamp):

Member ID#: Date of Birth: Mailing Address:

Clinic Name: Phone:

Apt #: City:

Zipcode:

MUST INCLUDE MEDICAL RECORD DOCUMENTATION WITH FLYER TO RECEIVE GIFT REWARD

Phone #:

Mail or fax the completed form to: Mail: Molina Healthcare of Washington Attn: Quality Health Education PO Box 4004 Bothell, WA 98041

Fax:

Attn: Quality Health Education (800) 461-3234

MolinaHealthcare.com

If you need help finding a doctor, please call (800) 869-7165 (TTY 711) You will receive your gift reward within 4 to 6 weeks after processing and verification. Please note: Each member is eligible for up to $200 of rewards per calendar year. 2682446WA0715

English

If you need this information in a different format or language, call Molina Healthcare at (800) 869-7165. Spanish Si necesita esta información en un formato o idioma diferente, llame a Molina Healthcare al (800) 869-7165. Armenian Այս տեղեկատվությունը մեկ այլ ձևաչափով կամ լեզվով ստանալու համար, զանգահարեք Մոլինա Առողջապահություն (800) 869-7165. Hindi यदि आपको यह जानकारी भिनन ् फॅार्मेट अथवा िाषा र्ें चादहए तो र्ोभिना है िथक ् े यर को (800) 869-7165 पर कॉि करें । Hmong Yog koj xav tau cov xov xwm no ua lwm tus qauv lossis lwm hom lus, hu rau Molina Healthcare ntawm (800) 869-7165. Lao ້ ນໃນແບບຕ່າງ ຫຼ ື ພາສາອື່ນ, ໂທກາອົງການດູແລສຸ ຂະພາບໂມລີນ່າທີ່ (800) 869-7165. ຖ້າທ່ ານຢາກໄດ້ຂໍມູ Khmer ប្រសិនប្រើបោកអ្នកប្រូវការព័្មា ៌ នបនះ ជាទប្រង់ និងភាសាប្សេងគ្្ន សូ ្របៅទូរស័ព្ទ្រក Molina Healthcare គឺបេខ៖ (800) 869-7165។ Korean 다른 포맷이나 언어로 정보를 이용하려면, 몰리나 보건 사업부 (800) 869-7165에 문의하십시오. Punjabi ਜੇਕਰ ਤੁਹਾਨੂੰ ਇਸ ਜਾਣਕਾਰੀ ਦੀ ਵੱ ਖਰੇ ਪ੍ਾਰੂਪ ਜਾਂ ਭਾਸ਼ਾ ਵਵੱ ਚ ਲੋ ੜ ਹੈ, ਤਾਂ ਮੋਲੀਨਾ ਹੈਲਥਕੇਅਰ ਨੂੰ (800) 869-7165 ਤੇ ਕਾੱਲ ਕਰੋ। Romanian În cazul în care aveți nevoie de aceste informații într-o formă sau limbă diferite, apelați Molina Healthcare la (800) 869-7165. Ukranian Якщо ви бажаєте отримати цю інформацію в іншому форматі чи іншою мовою, зателефонуйте в компанію Molina Healthcare на номер (800) 869-7165. Russian Если данная информация нужна вам в другом формате или на другом языке, позвоните в компанию Molina Healthcare по телефону (800) 869-7165. Somali Haddii aad warbixintan ku rabto qaab kale ama luuqad kale, ka wac Molina Healthcare (800) 869-7165. Tigrinya እንተደኣ ነዚ ሓበሬታ ብካልእ ቅርጺ ወይም ቋንቋ ደሊኩም፣ ናብ Molina Healthcare ብቊጽሪ ስልኪ (800) 869-7165 ደውሉ። Traditional Chinese 如果您需要不同格式或不同語種的此資訊，請致電Molina醫療保健：(800) 869-7165 。 Vietnamese Nếu bạn cần thông tin này ở định dạng hoặc bằng ngôn ngữ khác, hãy gọi cho Molina Healthcare theo số (800) 869-7165. Samoan Pe a e manaomia lenei faamatalaga ise faatulagaga ese poo se isi gagana, telefoni atu ia Molina Healthcare ile (800) 869-7165. Amharic ይህንን መረጃ በሌላ ቅርጽ ወይም ቋንቋ ለማግኘት ከፈለጉ፣ ለሞሊና የጤና ማዕከል በስልክ ቁጥር (800) 869-7165 ይደውሉ።

45079 WA Medicaid Staying Healthy with Diabetes Letter.indd 2

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Mammography Who? Women should have mammograms every two years from age 50 to 74. If you are 40 to 49 years old, talk to your doctor about when to start and how often to get a screening mammogram. Talk to your healthcare provider if you have any symptoms or changes in your breast. If breast cancer runs in your family, your provider may recommend that you have mammograms before age 50 or more often than usual. What? A mammogram is an X-ray picture of the breast and takes only a few moments. Doctors use a mammogram to look for early signs of breast cancer. Why? Regular mammograms are the best tests doctors have to find breast cancer early, sometimes up to three years before it can be felt. When breast cancer is found early, many women go on to live long and healthy lives. Get your recommended Mammography Screening! Only females between the age of 50-74 are eligible for this reward. You must have had the mammogram in 2016. Make sure to complete the entire form and include provider signature. Make sure to mail this postcard back to Molina Healthcare to get your $15 reward. Member Name: ____________________________________________________ Date of Birth: _____________________________________________________ Address: _________________________________________________________ City:____________________________________________________________ State:___________________________________________________________ Zip Code:_________________________________________________________ Phone Number: ____________________________________________________ Date of Exam: _____________________________________________________ Provider Name: ____________________________________________________ Results: _________________________________________________________ Provider Address: __________________________________________________ Provider Phone: ___________________________________________________ Provider Signature: _________________________________________________





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Colorectal Cancer Screening Who? Both men and women age 50-75. People at higher risk of developing colorectal cancer should begin screening at a younger age, and may need to be tested more frequently. What? High-sensitivity fecal occult blood test (FOBT): Every year (Complete in 2016) Flexible sigmoidoscopy: Every 5 years (Completed between 2012-2016) Colonoscopy: Every 10 years (Completed between 2007-2016) Talk to your doctor about which screening you should have done. Why? Colorectal cancer almost always develops from precancerous polyps (abnormal growths) in the colon or rectum. Screening tests can find precancerous polyps, which can often be removed before cancer develops. Screening tests find colorectal cancer early, when treatment works best. Get your recommended Colorectal Cancer Screening! Only men and women age 50-75 who get one of the recommended colorectal cancer screenings within the time frames above are eligible for a reward. Make sure to complete the entire form and include provider signature. Make sure to mail this postcard back to Molina Healthcare to get your $15 reward. Member Name: ____________________________________________________ Date of Birth: _____________________________________________________ Address: _________________________________________________________ City:____________________________________________________________ State:___________________________________________________________ Zip Code:_________________________________________________________ Phone Number: ____________________________________________________ Date of Exam: _____________________________________________________ Provider Name: ____________________________________________________ Results: _________________________________________________________ Type of Screening: _________________________________________________ Provider Address: __________________________________________________ Provider Phone: ___________________________________________________ Provider Signature: _________________________________________________ MolinaHealthcare.com/Medicare 3645240 CORP Medicare Planner Postcard Flyer.indd 4

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Annual Flu Vaccine Who? Everyone 6 months of age and older should get a flu vaccine every season. What? Flu vaccines are designed to protect against the main flu viruses that research suggests will be the most common during the upcoming season. Three kinds of flu viruses commonly circulate among people today: influenza A (H1N1) viruses, influenza A (H3N2) viruses, and influenza B viruses. Why? Certain people are at greater risk for serious complications if they get the flu. This includes older people, young children, pregnant women and people with certain health conditions (such as asthma, diabetes, or heart disease). Complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. Get your annual Flu Vaccine! If you get your flu shot between September 1 2016 - December 31 2016, you are eligible for this reward. Make sure to mail complete the entire form and include provider signature. Make sure to mail postcard back to Molina Healthcare to get your $15 reward. Member Name: ____________________________________________________ Date of Birth: _____________________________________________________ Address: _________________________________________________________ City:____________________________________________________________ State:___________________________________________________________ Zip Code:_________________________________________________________ Phone Number: ____________________________________________________ Date you got your flu shot: ____________________________________________ Where did you get your flu shot? ☐ Pharmacy Name: ________________________________________________ ☐ Provider Name: __________________________________________________ Provider/Pharmacy Address: __________________________________________ Provider/Pharmacy Phone: ____________________________________________ Provider or Technician Signature: _______________________________________



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Diabetes Care Who? Members who are age 18-75 and have been diagnosed with either type of diabetes, type 1 or type 2. What? A1C Testing: administered every 3-6 months. The A1C test can help determine how well your diabetes treatment plan is working, by reviewing the average blood glucose control for the past 2 to 3 months. Nephropathy Screening: a Nephropathy Screening is a urine test recommended to be done annually to reduce the risk of diabetic nephropathy. Early detection can reduce the risk for kidney damage and failure. Why? Diabetes can affect different parts of the body. Without the proper treatment and monitoring, diabetes has the potential to cause a range of complications. Routine monitoring can detect the early stages of complications and can help to prevent amputation, blindness, and kidney failure. Get your recommended Diabetes Screenings! You must complete at least one A1c test and one urine test during 2016 to be eligible to get the reward. This reward can only be redeemed once. Be sure to complete the entire form and include provider signature. Make sure to mail this postcard back to Molina Healthcare to get your $15 reward. Member Name: _____________________________________________________ Date of Birth: ______________________________________________________ Address: __________________________________________________________ City:_______________________________State:______ Zip Code:_____________ Phone Number: _____________________________________________________ Provider Name/Location ______________________________________________ Phone Number: _____________________________________________________ Date of A1c Test:____________________________________________________ Results: __________________________________________________________ Date of Nephropathy Test: _____________________________________________ Results: __________________________________________________________ Provider or Technician Signature: ________________________________________ MolinaHealthcare.com/Medicare 3645240 CORP Medicare Planner Postcard Flyer.indd 8

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