Smmc Refresher Quiz #5
Good Cause Reasons
- 1.
A recipient states, “I have been seeing my husband’s provider and paying out of pocket, but they told me yesterday that they accept one of the Medicaid plans in my area. Can I change my plan?”The recipient is locked in. What Good Cause can you attempt to use?
- A.
Good Cause 1 - because the doctor isn’t accepting the current plan anymore.
- B.
The recipient does not qualify for a Good Cause Plan Change at this time.
- C.
Good Cause 9 - because they have an active relationship with a provider.
- D.
Good Cause 4 - because the current plan is unable to provide effective care.
Correct Answer
C. Good Cause 9 - because they have an active relationship with a provider. -
- 2.
A recipient states, “The pills my provider gave me actually made my condition worse. My doctor thinks I need a different prescription, but my plan won’t cover it!”The recipient is locked in. What Good Cause can you attempt to use?
- A.
Good Cause 4 - because the plan is unable to provide effective care.
- B.
Good Cause 13 - because the plan may not provide the prescription due to moral or religious objections.
- C.
Good Cause 17 - because the recipient needs a specialty plan that will cover the medications.
- D.
The recipient does not qualify for a Good Cause Plan Change at this time.
Correct Answer
A. Good Cause 4 - because the plan is unable to provide effective care. -
- 3.
A recipient states, “I need to change my plan because I don’t like it anymore.” You probe for more information, but the recipient offers no other reasons to change.The recipient is locked in. What Good Cause can you attempt to use?
- A.
Good Cause 4 - because the plan is unable to provide effective care.
- B.
The recipient does not qualify for a Good Cause Plan Change at this time, provide the next OE dates.
- C.
Good Cause 1 - because it will allow the change to be processed without approval and will get the recipient off of the phone.
- D.
Inform the recipient of the Good Cause Reasons so they can choose which one best fits their situation.
Correct Answer
B. The recipient does not qualify for a Good Cause Plan Change at this time, provide the next OE dates. -
- 4.
A recipient states “My doctor sent me a letter that says that they’ve stopped accepting my plan. I don’t want to change my doctor.”The recipient is locked in. What Good Cause can you attempt to use?
- A.
Good Cause 1 - because the provider is no longer accepting the plan.
- B.
Good Cause 9 - because the recipient has an active relationship with the provider.
- C.
Good Cause 4 - because the plan is unable to provide effective care.
- D.
The recipient does not qualify for a Good Cause Plan Change at this time.
Correct Answer
A. Good Cause 1 - because the provider is no longer accepting the plan. -
- 5.
A recipient states, “My doctor is over an hour away, and they are the only provider in my area that accepts my plan! My sister goes to a doctor right down the road, can I change my plan so I can see a doctor closer to me?”The recipient is locked in. What Good Cause can you attempt to use?
- A.
Good Cause 1 - because the provider does not accept the current plan.
- B.
Good Cause 9 - because the recipient has an active relationship with the provider.
- C.
Good Cause 4 - because the current plan is unable to provide effective care.
- D.
Good Cause 1622 - because the provider is too far away.
Correct Answer
D. Good Cause 1622 - because the provider is too far away. -
- 6.
A recipient states, “My doctor tells me I need to change my plan to something called ‘Positive Healthcare’. He says my current plan won’t cover the treatments I need, but this other plan will.”The recipient is locked in and has an active HIV/AIDS span in HealthTrack. What Good Cause can you attempt to use?
- A.
Good Cause 4 - because the current plan is unable to provide effective care.
- B.
Good Cause 17 - because the recipient is changing to a specialty plan.
- C.
Good Cause 9 - because the recipient has an active relationship with the provider.
- D.
The recipient does not qualify for a Good Cause Plan Change at this time.
Correct Answer
B. Good Cause 17 - because the recipient is changing to a specialty plan. -
- 7.
A recipient's plan is no longer covering the pain medication they have been taking for a back injury. You attempt to use a Good Cause 4, but it is denied because the recipient has not filed a grievance with the plan. The recipient states, "I need to change my plan now! If I run out of this medication I will be in severe pain!"How should you proceed?
- A.
File a complaint in HealthTrack and refer the recipient to the plan to file a grievance.
- B.
Refer the recipient to AHCA to file a complaint.
- C.
Advise the recipient that they are not able to change the plan at this time and provide the Open Enrollment dates.
- D.
Refer the recipient to SNU because they will convince the plan to cover the medication.
Correct Answer
A. File a complaint in HealthTrack and refer the recipient to the plan to file a grievance. -
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Current Version
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Mar 19, 2022Quiz Edited by
ProProfs Editorial Team -
Apr 10, 2017Quiz Created by
AHSFLTrainer
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