2018 Fl Smmc Healthtrack Enrollee Information Quiz

1. An enrollee wants to know if they can change their plan. When reviewing the case you see they are Medicaid Pending and enrolled in Sunshine Health. What options are available to this recipient?

• The enrollee can change to any other available LTC plan.

• Inform the recipient they are not eligible to make a plan change because they are in their Lock-in period.

• The enrollee can remain in Sunshine Health or disenroll from the LTC program to stop services until Medicaid is approved.

• Refer the recipient to DOEA to get an exemption because LTC recipients do not make plan changes without exemptions.

The enrollee, who is Medicaid Pending and enrolled in Sunshine Health, has the option to either remain in Sunshine Health or disenroll from the LTC program until Medicaid is approved. This means that they can continue receiving services from Sunshine Health or temporarily stop receiving services until their Medicaid application is approved.

Explanation

The enrollee, who is Medicaid Pending and enrolled in Sunshine Health, has the option to either remain in Sunshine Health or disenroll from the LTC program until Medicaid is approved. This means that they can continue receiving services from Sunshine Health or temporarily stop receiving services until their Medicaid application is approved.

2. If a newly eligible member has an active SMI and HIV Span, which specialty plan will the enrollee be auto-assigned to based on the specialty plan hierarchy?

Sunshine Health Child Welfare

Magellan Complete Care

Children's Medical Services

Positive Healthcare/Clear Health Alliance

If a newly eligible member has an active SMI and HIV Span, they will be auto-assigned to the Positive Healthcare/Clear Health Alliance specialty plan based on the specialty plan hierarchy.

Explanation

If a newly eligible member has an active SMI and HIV Span, they will be auto-assigned to the Positive Healthcare/Clear Health Alliance specialty plan based on the specialty plan hierarchy.

3. The enrollee states they are new to Medicaid and wants to make a plan change because their PCP doesn't accept their current plan. When reviewing their case you see they just received Medicaid eligibility 8/1/2017, and the plan just became effective 9/1/2017. Today is 10/1/2017. Can the enrollee make a plan change?

• No, they are currently in a no change period.

• Yes, they qualify for a Good Cause plan change.

• No, they are a mandatory enrollee and must keep current plan.

• Yes, they are currently in their 120 day change period.

The enrollee can make a plan change because they are currently in their 120 day change period. This means that within 120 days of becoming eligible for Medicaid, they have the opportunity to switch plans if their PCP does not accept their current plan. Since the enrollee received Medicaid eligibility on 8/1/2017 and the plan became effective on 9/1/2017, they are still within the 120 day change period as today is 10/1/2017.

Explanation

The enrollee can make a plan change because they are currently in their 120 day change period. This means that within 120 days of becoming eligible for Medicaid, they have the opportunity to switch plans if their PCP does not accept their current plan. Since the enrollee received Medicaid eligibility on 8/1/2017 and the plan became effective on 9/1/2017, they are still within the 120 day change period as today is 10/1/2017.

4. The recipient calls to enroll into a managed care plan. What are their enrollment options?

• Only FFS because they are voluntary.

• Cannot enroll into a plan because of an active TPL on file.

• The recipient is voluntary because of the TPL 14 on file and they have the options of either remaining on FFS or enrolling into a health plan.

• Only enroll into a plan and cannot have FFS because of the TPL on file.

The recipient is considered voluntary because of the TPL 14 on file. This means that they have the choice to either remain on FFS (Fee-for-Service) or enroll into a health plan. They are not limited to only one option and can choose whichever option suits them best. The TPL on file does not prevent them from enrolling into a health plan.

Explanation

The recipient is considered voluntary because of the TPL 14 on file. This means that they have the choice to either remain on FFS (Fee-for-Service) or enroll into a health plan. They are not limited to only one option and can choose whichever option suits them best. The TPL on file does not prevent them from enrolling into a health plan.

5. The recipient calls to enroll into a plan, but when reviewing the MMA hover you see there is an exemption on file. What is the best way to proceed?

• Inform the recipient they cannot enroll into a plan because they are exempt from being able to have any kind of Medicaid coverage.

• Inform the recipient they have APD and cannot enroll into a plan. Refer the recipient to DCF to have the demise date removed.

• Inform the recipient they are dually eligible due to the exemption and can only have FFS.

• Inform the recipient they cannot enroll into a plan because there is an exemption on the case.

The best way to proceed is to inform the recipient that they cannot enroll into a plan because there is an exemption on the case. This means that they are exempt from being able to have any kind of Medicaid coverage.

Explanation

The best way to proceed is to inform the recipient that they cannot enroll into a plan because there is an exemption on the case. This means that they are exempt from being able to have any kind of Medicaid coverage.

6. Why is the enrollee listed below Excluded from enrolling into a LTC plan?

• Enrollee is receiving Medicaid from the Social Security Administration.

• Enrollee has APD: IC meaning they are currently incarcerated.

• Medicaid ended on 9/1/2010.

• Enrollee is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities.

The enrollee is excluded from enrolling into a LTC plan because they are currently living in an Intermediate Care Facility for Persons with Developmental Disabilities. This indicates that they are already receiving care and support in a specialized facility, and therefore do not need additional coverage from a LTC plan.

Explanation

The enrollee is excluded from enrolling into a LTC plan because they are currently living in an Intermediate Care Facility for Persons with Developmental Disabilities. This indicates that they are already receiving care and support in a specialized facility, and therefore do not need additional coverage from a LTC plan.

7. Why is the enrollee below categorized as Voluntary?

• The enrollee has (LTCC) indicator next to his level of care.

• The enrollee has APD: WL meaning he is on the Agency for Persons with Disabilities Waitlist.

• The enrollee has (MWA) ACWM.

• The enrollee has APD: WL meaning he is on the Weight Loss Waiver Program.

The enrollee is categorized as Voluntary because he is on the Agency for Persons with Disabilities (APD) Waitlist. This indicates that he has voluntarily chosen to be on the waitlist for services provided by the APD. The other indicators such as LTCC, MWA, and APD: WL (Weight Loss Waiver Program) are not relevant to determining the enrollee's categorization as Voluntary.

Explanation

The enrollee is categorized as Voluntary because he is on the Agency for Persons with Disabilities (APD) Waitlist. This indicates that he has voluntarily chosen to be on the waitlist for services provided by the APD. The other indicators such as LTCC, MWA, and APD: WL (Weight Loss Waiver Program) are not relevant to determining the enrollee's categorization as Voluntary.

8. What does a "T" shown for the enrollee's LTC eligibility category mean?

• The enrollee's LTC coverage has been terminated and they are no longer receiving services.

• The enrollee experienced a temporary loss and must pay for services until coverage is reinstated.

• The enrollee has experienced a temporary loss and will continue to receive services at no charge for 60 days.

• The enrollee is not eligible to be enrolled into a LTC plan.

The "T" shown for the enrollee's LTC eligibility category means that the enrollee has experienced a temporary loss and will continue to receive services at no charge for 60 days. This indicates that the enrollee's coverage has not been terminated but is temporarily suspended, and they will still receive the necessary services without any cost for a limited period of time.

Explanation

The "T" shown for the enrollee's LTC eligibility category means that the enrollee has experienced a temporary loss and will continue to receive services at no charge for 60 days. This indicates that the enrollee's coverage has not been terminated but is temporarily suspended, and they will still receive the necessary services without any cost for a limited period of time.

9. This enrollee needs to update their address, where should they call?

• AHCA

• DOEA

• DCF

• SSA

Enrollees who need to update their address should call the Social Security Administration (SSA). The SSA is responsible for managing and maintaining individuals' Social Security records, including their address information. By calling the SSA, the enrollee can provide their updated address and ensure that their records are updated accordingly.

Explanation

Enrollees who need to update their address should call the Social Security Administration (SSA). The SSA is responsible for managing and maintaining individuals' Social Security records, including their address information. By calling the SSA, the enrollee can provide their updated address and ensure that their records are updated accordingly.

10. When reviewing a case, you see the recipient has an active QMB eligibility span and a TPL 11 on file. How would you describe this enrollee's eligibility?

• The recipient will use FFS Medicaid to get services. Medicaid is primary and the private insurance is secondary.

• The Recipient has QMB, it is not full Medicaid coverage. It covers Medicare premiums, deductibles and coinsurance. The recipient also has a Medicare Special Needs plan (TPL 11) that will cover services.

• The recipient has Share of Cost. Medicaid will pay any service that is not covered by Medicare.

• The recipient has a Special Needs Plan that will cover 80% of services and QMB will cover the other 20% for doctor's visits and prescriptions.

The recipient has QMB eligibility, which means they have coverage for Medicare premiums, deductibles, and coinsurance. However, this is not full Medicaid coverage. Additionally, the recipient has a Medicare Special Needs plan (TPL 11) that will cover services. This means that Medicaid is primary and the private insurance is secondary, with the recipient using FFS Medicaid to receive services.

Explanation

The recipient has QMB eligibility, which means they have coverage for Medicare premiums, deductibles, and coinsurance. However, this is not full Medicaid coverage. Additionally, the recipient has a Medicare Special Needs plan (TPL 11) that will cover services. This means that Medicaid is primary and the private insurance is secondary, with the recipient using FFS Medicaid to receive services.

11. The caller needs to know what plan their child has, and when reviewing the case you see a "K" for the eligibility category and the child is enrolled in Sunshine Health. How do you proceed?

• Refer to Sunshine Health

• Refer to DCF

• Refer to the MediKids Helpline

• Refer to AHCA

Based on the given information, the caller needs to know what plan their child has and the child is enrolled in Sunshine Health. However, the eligibility category is mentioned as "K". To proceed, it would be appropriate to refer the caller to the MediKids Helpline. This helpline can provide more specific information regarding the child's plan and eligibility category.

Explanation

Based on the given information, the caller needs to know what plan their child has and the child is enrolled in Sunshine Health. However, the eligibility category is mentioned as "K". To proceed, it would be appropriate to refer the caller to the MediKids Helpline. This helpline can provide more specific information regarding the child's plan and eligibility category.

12. Mary does not want to be enrolled in a managed care plan anymore. She prefers to receive services using straight Medicaid because they have better doctors and she does not have to get referrals to see her specialist. How do you proceed?

• Submit a MC Exemption request to AHCA without supervisor approval because the enrollee wants straight Medicaid for a good reason.

• File a complaint against AHCA. Florida statute states enrollees have the right to choose a managed care plan or straight Medicaid.

• Submit a Supervisor Task for SNU because the caller needs to see her specialists.

• Explain to the caller that she must be enrolled in a managed care plan in order to receive services. Refer to DCF/SSA for eligibility redetermination. Exemption requests should only be filed with supervisor approval.

The correct answer is to explain to the caller that she must be enrolled in a managed care plan in order to receive services. This is because the caller prefers to receive services using straight Medicaid, but it is necessary for her to be enrolled in a managed care plan. The answer also suggests referring the caller to DCF/SSA for eligibility redetermination and states that exemption requests should only be filed with supervisor approval.

Explanation

The correct answer is to explain to the caller that she must be enrolled in a managed care plan in order to receive services. This is because the caller prefers to receive services using straight Medicaid, but it is necessary for her to be enrolled in a managed care plan. The answer also suggests referring the caller to DCF/SSA for eligibility redetermination and states that exemption requests should only be filed with supervisor approval.

13. What should you do if the HIV/AIDS special condition is not listed in the system?

• Tell the caller their doctor must update their medical record and report it to AHCA.

• Tell the caller to fax us documentation of the special condition, so the case can be updated.

• Tell the caller they must report their special condition to the Centers for Disease Control and the Department of Health.

• Tell the caller the SNU Nurse will call them to get more information on their special condition and set up a home visit.

If the HIV/AIDS special condition is not listed in the system, the appropriate action would be to tell the caller to fax documentation of the special condition. This is necessary in order to update the case and ensure that the proper information is recorded.

Explanation

If the HIV/AIDS special condition is not listed in the system, the appropriate action would be to tell the caller to fax documentation of the special condition. This is necessary in order to update the case and ensure that the proper information is recorded.

14. An enrollee wants to know what kind of coverage they have. When reviewing the case you see the enrollee has a PACE Level of Care and is enrolled in a PACE plan. What can you inform the enrollee of their coverage?

• The enrollee is enrolled in PACE and will receive medical and Long-Term Care services from PACE.

• The enrollee has a private insurance on file and will receive all services through the private insurance.

• The enrollee receives LTC services through the PACE plan because they are disabled, so they can use FFS for their medical coverage.

• All PACE enrollees qualify to receive extra benefits through LTC plans.

The enrollee has a PACE Level of Care and is enrolled in a PACE plan, which means they will receive medical and Long-Term Care services from PACE. This indicates that their coverage is provided by PACE and they can expect to receive the necessary healthcare services from this plan.

Explanation

The enrollee has a PACE Level of Care and is enrolled in a PACE plan, which means they will receive medical and Long-Term Care services from PACE. This indicates that their coverage is provided by PACE and they can expect to receive the necessary healthcare services from this plan.

15. Which of the following is Voluntary for an MMA enrollment?

• Recipients that receive Supplemental Security Income

• Recipients with APD

Recipients with Medicare

• Recipients that are in foster care

Recipients with APD refers to individuals who have been diagnosed with an Acquired Perceptual Deficit. This condition affects their ability to process sensory information, which can impact their daily functioning. Enrollment in an MMA (Medicare Modernization Act) program is voluntary for individuals with APD, meaning they have the choice to enroll or not.

Explanation

Recipients with APD refers to individuals who have been diagnosed with an Acquired Perceptual Deficit. This condition affects their ability to process sensory information, which can impact their daily functioning. Enrollment in an MMA (Medicare Modernization Act) program is voluntary for individuals with APD, meaning they have the choice to enroll or not.

16. If the enrollee has an active CMS span on file...

• then the CMS questions will not have to be asked.

• then they will have to contact CMS directly to enroll.

• then the CMS questions have to be asked.

• then they cannot enroll into CMS.

If the enrollee has an active CMS span on file, it means that their information and enrollment status with CMS (Centers for Medicare and Medicaid Services) is already known and up to date. Therefore, there is no need to ask the CMS questions again as the information is already available.

Explanation

If the enrollee has an active CMS span on file, it means that their information and enrollment status with CMS (Centers for Medicare and Medicaid Services) is already known and up to date. Therefore, there is no need to ask the CMS questions again as the information is already available.

17. If the CMS special condition expires...

• then the child will have 60 days to continue to receive services from CMS.

• then the child has been cured of the special condition.

• then the child can enroll into CMS.

• then the child will be disenrolled from CMS.

If the CMS special condition expires, it means that the child no longer meets the criteria for receiving services from CMS. Therefore, the child will be disenrolled from CMS.

Explanation

If the CMS special condition expires, it means that the child no longer meets the criteria for receiving services from CMS. Therefore, the child will be disenrolled from CMS.

18. If a newly eligible child has an active CMS and HOMESAFENET span, which specialty plan will the enrollee be auto-assigned to based on the specialty plan hierarchy?

• Sunshine Health Child Welfare

• Magellan Complete Care

• Children's Medical Services

• Positive Healthcare/Clear Health Alliance

If a newly eligible child has an active CMS and HOMESAFENET span, they will be auto-assigned to the Sunshine Health Child Welfare specialty plan based on the specialty plan hierarchy.

Explanation

If a newly eligible child has an active CMS and HOMESAFENET span, they will be auto-assigned to the Sunshine Health Child Welfare specialty plan based on the specialty plan hierarchy.

19. Flora says she received a letter saying she is Medicaid eligible and she wants to choose a plan. She has been advised that the type of Medicaid she has will not allow her to enroll into a plan, so she wants to know what kind of coverage she has. You look in HealthTrack and see Flora has a QI1 active span. What can you inform Flora about her coverage?

• Tell Flora, she can't choose a plan and discontinue the call.

• Advise Flora that Medicare is her primary insurance and she has limited Medicaid coverage that covers Medicare part B premiums.

• Submit a discrepancy log to request for Flora to be enrolled into a plan.

• Advise Flora that she can't pick a plan because she has FFS.

Flora has a QI1 active span, which means that she has limited Medicaid coverage that covers Medicare part B premiums. Therefore, she cannot choose a plan, but she can be informed that Medicare is her primary insurance and she has coverage for Medicare part B premiums through Medicaid.

Explanation

Flora has a QI1 active span, which means that she has limited Medicaid coverage that covers Medicare part B premiums. Therefore, she cannot choose a plan, but she can be informed that Medicare is her primary insurance and she has coverage for Medicare part B premiums through Medicaid.

20. When a recipient has an "A" or "N" in HT for MMA, you should...

• Refer the caller to DCF/SSA because they are not eligible yet.

• Do not ask questions and automatically transfer to Express Enrollment.

• Follow the script to determine if the recipient needs to be transferred to Express Enrollment.

• Advise the recipient to allow 24-48 business hours for their eligibility to update and call back.

If a recipient has an "A" or "N" in HT for MMA, the correct action is to follow the script to determine if the recipient needs to be transferred to Express Enrollment. This means that the recipient's eligibility for Express Enrollment will be assessed based on the information provided in the script, and a decision will be made accordingly. The other options, such as referring the caller to DCF/SSA or automatically transferring to Express Enrollment without asking questions, are not appropriate in this situation. Advising the recipient to allow 24-48 business hours for their eligibility to update and call back is also not the correct action to take.

Explanation

If a recipient has an "A" or "N" in HT for MMA, the correct action is to follow the script to determine if the recipient needs to be transferred to Express Enrollment. This means that the recipient's eligibility for Express Enrollment will be assessed based on the information provided in the script, and a decision will be made accordingly. The other options, such as referring the caller to DCF/SSA or automatically transferring to Express Enrollment without asking questions, are not appropriate in this situation. Advising the recipient to allow 24-48 business hours for their eligibility to update and call back is also not the correct action to take.