Dec 26-refresher Activity 2

The member received the 'LTC Welcome-Non-Fully Eligible' letter because they have submitted a Medicaid Application and have established a Level of Care. This means that the member is Application Pending, and as a result, they have the ability to enroll into an LTC plan. The letter serves as an acknowledgement of their application and informs them that they can proceed with enrolling into an LTC plan while waiting for approval from DCF.

This request is a Good Cause plan change request to CMS. The term "Good Cause" suggests that there is a valid reason or justification for the plan change. The request is being made to CMS, which indicates that it is related to some sort of healthcare or insurance plan.

This LTC enrollment request is categorized as "Medicaid Pending" because it indicates that the individual's Medicaid application is still being processed and their eligibility for long-term care services is pending.

The complaint is in the "Open" status.

The member's current Medicaid began on 06/01/2008.

The recipient has Medicare coverage because the answer provided is "Yes". This indicates that the recipient is covered by Medicare, a federal health insurance program in the United States for individuals who are 65 years old or older, or have certain disabilities.

The member is currently enrolled in the SMMC MMA Capitated plan effective 11/01/2014. This can be determined by looking at the dates mentioned for each plan. The SMMC Long-Term Care (LTCC) plan was effective from 09/01/2014, the Medicaid HMO plan was effective from 12/01/2012, and the SMMC MMA Capitated plan was effective from 09/01/2014 and again from 11/01/2014. Therefore, the most recent plan that the member is enrolled in is the SMMC MMA Capitated plan effective 11/01/2014.

The active special condition was last updated on 04/30/2014.

The recipient has the ACWM of MS.

GC1 would apply in this situation because the caller wants to change their plan in order to continue seeing their preferred doctor. GC1 states that if a caller wants to change their plan in order to continue seeing a specific provider, they should be transferred to the appropriate department to discuss plan options.

Based on the given scenario, the caller claims to have a letter from the doctor's office stating that the PCP is no longer accepting the plan. To verify this information, the best course of action would be to ask the caller to fax the letter so that it can be sent to AHCA (Agency for Health Care Administration) for verification. This will allow the AHCA to confirm the validity of the letter and make the necessary adjustments to the plan if required.

The correct answer is GC1. GC1, also known as "Protecting the rights and interests of consumers," would be the most appropriate Good Cause to use in this situation. The caller is expressing concern about their current meal delivery company no longer accepting their plan. By selecting GC1, the agent would be demonstrating a commitment to ensuring that the customer's rights and interests are protected. This would involve exploring alternative plans that the company does accept, in order to provide the caller with a satisfactory solution.

The correct answer is the first option: "The grievance is a formal complaint filed by the recipient with the plan concerning issues." This option accurately defines what a grievance is, which is a formal complaint made by the recipient to the plan regarding any issues or concerns they may have.

If a PACE enrollee no longer needs LTC services, they can complete a disenrollment request. This means that they can formally request to be removed from the PACE program since they no longer require long-term care services.

The correct answer is "Member can only enroll in PACE." This means that the recipient is only eligible to enroll in the PACE plan and cannot choose any other plan options.

This answer is correct because PACE (Program of All-Inclusive Care for the Elderly) is a program that provides comprehensive medical and long-term care services for eligible individuals. It covers both medical services and long-term care services, making it an appropriate option for individuals who need both types of care. The fact that PACE provides both medical and LTC services makes it a valid reason for a member to be excluded under MMA.

This member has the option to either request to disenroll from the LTC program or to remain in their current plan.

The newborn's plan will be effective on November 1 because the question states that the infant is born on November 6. Therefore, the plan will start on the first day of the same month, which is November 1.

To proceed with changing the plan for the newborn, the appropriate course of action is to process the plan change request through the wizard. This suggests that there is a specific system or tool in place that allows for the efficient and accurate processing of plan change requests. By utilizing the wizard, the necessary steps and information can be provided to facilitate the change in plan for the infant, ensuring a smooth transition to the desired plan.

The explanation for the given correct answer is that the cut-off date for LTC is the last day of the month. This means that any transactions or requests related to LTC must be completed or submitted by the end of the month in order to be considered for processing.

If a caller is not eligible for Freedom Health (Specialty Plan) but feels they should be eligible to enroll, the appropriate action would be to refer the caller to Freedom Health. This means directing the caller to contact Freedom Health directly for further assistance or clarification regarding their eligibility.

If the recipient does not want the specialty plan they are being Auto-Assigned to and they have a current, active MMA Auto-Assignment, the best course of action is to use the 'convert to voluntary choice' feature. This will give the recipient the option to choose their current plan voluntarily. This ensures that the recipient has control over their plan selection and can choose the plan that best suits their needs.

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Continuity of care is important for individuals with chronic conditions like seizures. By explaining continuity of care to the caller, they can understand the significance of maintaining their medication regimen. Advising the caller to contact their new plan and provide prescription information allows them to address the coverage issue directly. This approach ensures that the caller receives the necessary medication and avoids any potential disruptions in their treatment.

The recipient is referring to the service of Medication Administration. They are unable to take their pills out of the bottle due to their shaking hands and are also unable to fill the syringe with medicine for their Diabetes shot. Medication Administration would involve someone assisting them with taking their medications and administering the Diabetes shot.

The recipient is referring to Caregiver Training. They have recently moved in with their grandmother who has dementia and multiple medical complications. They express a lack of familiarity with her illness and how to help her, indicating a need for training in order to provide the necessary care and support.

The recipient is referring to Home Delivered Meals as the covered service. They mention that they don't have anyone to help them cook, so they need to have their food brought to their house. Home Delivered Meals specifically caters to individuals who are unable to prepare their own meals and provides them with nutritious meals that are delivered to their homes.

The recipient is referring to Personal Emergency Response Systems. This is evident from the statement that the mother needs the help bracelet she used to wear, indicating that she requires a device that can provide immediate assistance in case of accidents or emergencies.

Comprehensive Care Plans are indeed plans that provide services to recipients who are eligible for both the Medicare-Medicaid Alignment Initiative (MMA) and long-term care (LTC). These plans aim to coordinate and integrate care for individuals who qualify for both programs, ensuring they receive the necessary medical and long-term care services. Therefore, the statement is true.

After enrolling into an LTC plan, a care coordinator/case manager will be assigned to the enrollees. This care coordinator/case manager will have the responsibility of meeting with the enrollees to perform an assessment of their needs, developing a personalized plan of care, and assisting the enrollee in obtaining the appropriate care. The care coordinator/case manager will serve as a point of contact for the enrollees, providing them with additional assistance and coordinating their care to ensure they receive the necessary services and support.

Pending Choice refers to a situation where the recipient of a managed care plan can select a plan but will not receive any services until their Medicaid eligibility has been approved. This means that even though the recipient has chosen a plan, they cannot start receiving services until their Medicaid eligibility is confirmed. This option is different from the other choices provided, as it specifically mentions the recipient's ability to choose a plan and the requirement for Medicaid approval before services can begin.

The correct answer is "All of the above." This means that recipients who do not want to receive services before eligibility is granted have the option to choose a pending plan choice, which will be saved in the system until eligibility is received. They also have more time to decide on a service provider they are interested in, and they can call back to choose their care plan once eligibility is received.

The correct answer is "90 days will start on the first month eligibility has been received." This means that once a person becomes eligible for Med Pending enrollments, their 90-day trial period will begin in the first month of their eligibility.

If a caller claims to be an Emancipated Minor and is listed as their own payee, the correct course of action is to not continue with the call. Emancipated minors are individuals who have been legally granted independence from their parents or guardians. However, even if someone is an emancipated minor, it does not necessarily mean they have the authority to act as their own payee. Therefore, it is important to verify their claim and ensure that they have the necessary legal documentation before proceeding with any further actions.

A "temporary loss" for the MMA program is defined as a period of 180 days or less. This means that if an individual experiences a loss of income or employment for a period of 180 days or less, they would be considered to have a temporary loss and may be eligible for certain benefits or assistance under the MMA program.

Dr. Rufus Joseph accepts all of the mentioned plans, which include Clear Health Alliance, Magellan Complete Care, and Better Health. This means that patients with any of these plans can seek medical treatment from Dr. Rufus Joseph.

A MMA Specialty Plan is a type of plan that is specifically designed to serve Medicaid recipients who have special needs based on factors such as age, medical conditions, or diagnosis. This plan aims to provide specialized care and support to individuals who require additional assistance and resources due to their unique circumstances.

The correct answer is Doctors and specialist visits, prescription medication, hospital services, and transportation. This is because Florida's Managed Medical Assistance program aims to provide Medicaid services that include access to doctors and specialists, prescription medications, hospital services, and transportation for eligible individuals. It does not mention nursing home services, personal care, homemaker services, dental services, nursing facility, assisted living, or respite care.

The Quick Access Guide is where the Good Cause verbiage that may be used when processing a good cause plan change request can be found.

Escalated call notes do not need to be placed in all caps to convey the importance of the issue. The use of all caps can be seen as unprofessional and aggressive. Instead, the content of the notes should clearly and concisely explain the urgency and significance of the problem.