Molina Healthcare Updates Reimbursement Rates

Elina Sabilova, Billing Department, WCH

Effective November 1, 2025, Molina Healthcare revised updates to its reimbursement rates across multiple service categories, aligning them with the upcoming 2026 Medicare Physician Fee Schedule. These changes include both increases and adjustments that vary by specialty and code range. While some providers have reported upward revisions—particularly in primary care and select procedural categories—others have noted rate decreases in radiology and surgical services.

The key takeaway: there is no universal increase or cut. Different provider contracts and historical arrangements result in varied reimbursement impacts. All providers should review their updated fee schedules carefully, compare them with their current billed charges, and contact their Provider Relations Representative for clarification on any discrepancies.

Overview of the November 2025 Molina Update

Each fall, Molina Healthcare reviews its reimbursement rates to ensure alignment with federal and state payment policies. The November 2025 adjustment reflects changes derived from:

Updates to the Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F), released by CMS on October 31, 2025;

Adjustments to comply with Medicaid Managed Care rate-setting requirements;

Internal recalibration of certain CPT® and HCPCS code categories to reflect utilization, cost trends, and parity with Medicare benchmarks.

While the timing of the update corresponds with the release of the CMS final rule, not all Molina plans or contracts apply the new rates simultaneously. Some markets adopt the rates prospectively from January 1, 2026, while others implement interim adjustments in the final quarter of 2025.

Key Areas of Change

Primary Care and E/M Services

Molina has aligned reimbursement for most Evaluation and Management (E/M) codes with 85% of the Medicare rate.

Previously, some PCP contracts were reimbursed at 75%, meaning these providers will see an increase beginning in November.

The adjustment is consistent with Molina’s stated goal of strengthening primary care and behavioral health integration across its Medicaid and Medicare lines of business.

Radiology and Diagnostic Imaging

Radiology services have shown mixed adjustments.

In certain networks, reimbursement has decreased from 85% to 80% of Medicare rates, and in others from 75% to 70%, depending on regional benchmarks and prior contract terms.

These differences suggest that rates may now be standardized across markets where historical disparities existed. Providers are encouraged to compare current reimbursement to their contracted rates rather than assuming uniform changes.

Surgical Services

Most surgical CPT codes are now reimbursed at 80–85% of Medicare, depending on specialty.

Some previously enhanced rates (e.g., for outpatient procedures) were normalized to maintain consistency across the Molina provider network.

Behavioral and Mental Health Services

Telehealth behavioral services remain reimbursable under Molina’s policy, aligned with CMS’s continued telehealth coverage for behavioral care in 2026.

However, providers must ensure compliance with the reinstated in-person visit requirement effective October 1, 2025, for Medicare patients receiving mental health telehealth services.

Physician Services / HCPCS Codes

The update applies to “All applicable codes” under Molina’s Physician Services/HCPCS category. This includes procedure-based and time-based codes that are not captured in standard E/M or radiology ranges.

The fee adjustments mirror Medicare’s relative value changes but may vary slightly due to state-specific Medicaid adjustments.

Medicine Services (CPT 90281–99200, 99500–99999)

Molina’s current notice lists these codes, but not all of them are actively reimbursed in every network. Many correspond to immunization or prolonged service codes not used by all practices. Providers should confirm whether these codes are active in their specific fee schedule before assuming any rate change.

Why Fee Variations Exist

A single Molina update can affect providers differently for several reasons:

Contract Type – Legacy agreements or value-based care contracts may include negotiated percentages independent of the general fee schedule.

Line of Business – Rates often differ between Molina Medicare, Molina Marketplace, and Medicaid plans.

Geographic Adjusters – Molina applies regional conversion factors aligned with Medicare locality data, which may shift final rates by several percentage points.

Billing Practices – Providers using outdated fee schedules as their “billed charges” risk underbilling after increases. Conversely, those billing near prior higher rates may appear over threshold after downward adjustments.

Because of these variables, no single chart or example can accurately represent all Molina markets.

Early Observations from Providers

In the first weeks following implementation, feedback from network providers suggests:

Primary care physicians generally report modest reimbursement increases.

Radiology and imaging centers note reductions ranging from 5%–10%, depending on prior baseline.

Outpatient surgical centers observe mixed results—some CPT groups trending upward, others downward.

Behavioral health clinics report continued parity with prior rates but seek clarification on the intersection of state Medicaid telehealth policies and federal Medicare rules.

These variations underscore the importance of reviewing the actual fee schedule file provided through Molina’s secure provider portal, rather than relying on generic summaries or assumptions.

Recommended Provider Actions

1. Review Your Current Fee Schedule

Access your updated Molina Healthcare Fee Schedule (effective November 2025) through the Provider Portal or by contacting your Provider Relations Representative. Compare line-by-line reimbursement values against your current billed charges.

2. Adjust Billed Charges to Avoid Underpayments

If your billed charge is lower than Molina’s new fee, you may inadvertently cap your own reimbursement. Update your internal billing system to reflect at least the new schedule values.

3. Validate Your Contracted Percentage

Not all providers are paid at the same percentage of Medicare. Confirm whether your practice’s base reimbursement is calculated at 70%, 75%, 80%, or 85% of the Medicare rate for each service category.

4. Monitor Claim Remittances

For claims processed after November 1, verify that payments align with the new rates. Any discrepancies may indicate that the updated schedule was not yet loaded in Molina’s system or applied to your specific contract.

5. Contact Provider Relations for Clarification

If you see unexpected variances—especially within Radiology or Surgery—reach out to your Molina Provider Relations representative. Each plan may have its own implementation timeline or correction cycle.

6. Document and Communicate Internally

Ensure that your billing and administrative teams are aware of these changes. Internal misalignment between coding and accounting teams can result in claim resubmissions or denials.

What This Means for 2026

The Molina adjustment signals continued alignment between managed care payers and Medicare’s evolving reimbursement landscape. However, it also highlights an ongoing challenge for providers: a lack of uniformity across contracts.

As CMS transitions toward new resource-based valuations and revises conversion factors in the 2026 PFS, most commercial and Medicaid payers—including Molina—will continue recalibrating their fee schedules. Providers should anticipate another update in early Q2 2026, once CMS’s regional parity adjustments are finalized.

For now, the focus should remain on verifying that your systems reflect the November 2025 updates, particularly in:

E/M codes (CPT 99202–99499)

Diagnostic Imaging (CPT 70010–79999)

Surgical Services (CPT 10000–69990)

Mental and Behavioral Health (CPT 90791–90899)

Final Takeaways

Molina’s November 2025 updates do not represent across-the-board cuts or increases—impacts vary by contract, specialty, and region.

Primary Care and certain preventive services are trending upward toward 85% of Medicare.

Radiology and some surgical codes are being standardized, which may appear as rate reductions depending on prior levels.

Providers must actively review their new schedules, update billed charges, and verify payments on remittance advice.

Direct communication with Molina’s Provider Relations team remains the best way to confirm details specific to your practice.

This update is not a reason for alarm—it’s a prompt for attention. Fee changes are part of an annual cycle that reflects broader Medicare and Medicaid policy shifts. Providers who stay proactive—by reviewing, comparing, and communicating—will minimize disruptions and ensure accurate reimbursement through the year’s end.

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