Smmc: Written Assessment

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Smmc:  Written Assessment - Quiz

Questions and Answers
  • 1. 

    For details about benefits or prior authorizations that are not listed on the plan brochure, the recipient must call:

    • A.

      AHCA

    • B.

      The plan

    • C.

      DCF

    • D.

      SSA

    Correct Answer
    B. The plan
    Explanation
    The correct answer is "the plan" because the question is asking who the recipient should call for details about benefits or prior authorizations that are not listed on the plan brochure. It can be inferred that the plan referred to here is the healthcare plan or insurance plan that the recipient is enrolled in. Therefore, calling the plan directly would be the appropriate course of action to obtain the necessary information.

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  • 2. 

    Who can disenroll to terminate LTC services?

    • A.

      Recipients that need FFS because their provider doesn't accept a LTC plan.

    • B.

      Recipients that are currently residing in a nursing home.

    • C.

      Only recipients that are Voluntary.

    • D.

      Recipients that no longer need LTC services.

    Correct Answer
    D. Recipients that no longer need LTC services.
    Explanation
    Recipients who no longer need Long-Term Care (LTC) services can disenroll to terminate their LTC services. This means that if a recipient's condition improves or they no longer require the level of care provided by LTC services, they have the option to disenroll and end their participation in the program. This allows resources to be allocated to individuals who are in greater need of LTC services.

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  • 3. 

    MMA plans must provide continuity of care for up to _________ days.

    • A.

      90

    • B.

      30

    • C.

      180

    • D.

      60

    Correct Answer
    D. 60
    Explanation
    MMA plans must provide continuity of care for up to 60 days. This means that individuals who are enrolled in an MMA plan will have access to consistent and uninterrupted healthcare services for a period of 60 days. This ensures that individuals can receive the necessary medical treatments and services without any gaps or disruptions in their care. It is important for MMA plans to offer this continuity of care to promote the health and well-being of their members.

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  • 4. 

    Recipients with HOMESAFENET as an active special condition are eligible to enroll into which specialty plan?

    • A.

      Magellan Complete Care

    • B.

      Sunshine Health Child Welfare Plan

    • C.

      Children's Medical Services Network Specialty Plan

    • D.

      Sunshine Health

    Correct Answer
    B. Sunshine Health Child Welfare Plan
    Explanation
    Recipients with HOMESAFENET as an active special condition are eligible to enroll into the Sunshine Health Child Welfare Plan. This plan specifically caters to the needs of children in the child welfare system, ensuring they receive comprehensive healthcare services. Therefore, it is the appropriate specialty plan for recipients with HOMESAFENET as an active special condition.

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  • 5. 

    Sirena Robinson calls to verify the current plan for herself and her newborn child. When the counselor tells her she is not the authorized person on the case she states she has been emancipated from her mother.  Which statement is correct?

    • A.

      The counselor can continue with the call because Sirena stated that she is emancipated.

    • B.

      The call cannot continue because Sirena is under 18 years of age and counselors are never allowed to speak to members who are under age 18.

    • C.

      The counselor should notify Sirena that legal documentation of her emancipation must be faxed in before she can speak for herself; she can continue the call on the newborn's behalf.

    • D.

      Sirena must contact DCF to have a note placed on her case stating that she is emancipated.

    Correct Answer
    C. The counselor should notify Sirena that legal documentation of her emancipation must be faxed in before she can speak for herself; she can continue the call on the newborn's behalf.
    Explanation
    The correct answer is that the counselor should notify Sirena that legal documentation of her emancipation must be faxed in before she can speak for herself; she can continue the call on the newborn's behalf. This is because even though Sirena claims to be emancipated, the counselor needs proof of this emancipation before allowing her to speak on her own behalf.

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  • 6. 

    When a name is listed in the address field with C/O (in care of)...

    • A.

      The caller must still follow the normal verification procedures.

    • B.

      They are automatically authorized.

    • C.

      The caller must fax in legal documentation.

    Correct Answer
    A. The caller must still follow the normal verification procedures.
    Explanation
    When a name is listed in the address field with C/O (in care of), it means that the person receiving the mail or package is not the intended recipient, but rather someone who will pass it on to the recipient. In such cases, the caller must still follow the normal verification procedures to ensure that they are speaking to the correct person and have the necessary authorization. The C/O designation does not automatically authorize the caller, so they cannot skip the verification process.

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  • 7. 

    Rita Bailey calls in and states she wants to complain against her plan because she is being required to pay for services the plan is supposed to cover. What Issue Category should you select?

    • A.

      AHCA

    • B.

      Billing and Payment

    • C.

      Marketing

    • D.

      Network Access

    Correct Answer
    B. Billing and Payment
    Explanation
    The correct answer is Billing and Payment. This is because Rita Bailey is complaining about being required to pay for services that her plan is supposed to cover. This falls under the category of Billing and Payment as it involves issues related to the payment process and coverage of services.

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  • 8. 

    Anita Stephens calls in to complain against an AHS Choice Counseling Specialist because the agent  was "rude" and "disrespectful" when she requested a plan change yesterday. How should you proceed?

    • A.

      Escalate the call to a Supervisor for further assistance with the customer service issue.

    • B.

      Submit a call back request to have a Supervisor assist Anita.

    • C.

      Refer to AHCA Medicaid Helpline because they are required to process complaints against AHS.

    • D.

      Process the complaint request through HeathTrack and provide Anita with the complaint number.

    Correct Answer
    D. Process the complaint request through HeathTrack and provide Anita with the complaint number.
    Explanation
    In this scenario, Anita Stephens has called to complain about the behavior of an AHS Choice Counseling Specialist. The appropriate course of action would be to process the complaint request through HeathTrack, which is a system used for handling complaints. By doing so, Anita's complaint will be officially recorded and she will be provided with a complaint number for reference. This allows for proper documentation and tracking of the complaint.

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  • 9. 

    If a Mandatory recipient calls and states they want straight Medicaid, the agent should:

    • A.

      Immediately advise the caller that is not an option and end the call.

    • B.

      Advise the caller they are required to be in a plan to continue receiving services and ask what is their reason for wanting FFS/Straight Medicaid.

    • C.

      Advise the caller the request will be submitted and they will have straight Medicaid the 1st of the following month.

    • D.

      Submit the request to the supervisor for approval.

    Correct Answer
    B. Advise the caller they are required to be in a plan to continue receiving services and ask what is their reason for wanting FFS/Straight Medicaid.
    Explanation
    The correct answer is to advise the caller they are required to be in a plan to continue receiving services and ask what is their reason for wanting FFS/Straight Medicaid. This is the appropriate response because it addresses the caller's request while also informing them of the requirement to be in a plan. By asking for their reason, the agent can gather more information and potentially address any concerns or misconceptions the caller may have. It allows for a conversation to take place and for the agent to provide the necessary information and guidance.

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  • 10. 

    Caller states:  "I just started my new plan and just remembered I have an appointment with my old doctor for a procedure.  What should I do?" How should you proceed? 

    • A.

      Tell the caller the appointment needs to be cancelled and and re-scheduled with the new plan.

    • B.

      Explain Continuity of Care and refer to the new plan for more information.

    • C.

      Tell the caller the previous plan will cover services for up to 60 days.

    • D.

      Tell the caller the appointment will not be covered because the provider is not part of the MMA plan.

    Correct Answer
    B. Explain Continuity of Care and refer to the new plan for more information.
    Explanation
    The correct answer is to explain Continuity of Care and refer to the new plan for more information. This option acknowledges the caller's concern about their appointment with their old doctor and provides a solution by explaining the concept of Continuity of Care. By referring the caller to the new plan for more information, they can get specific details about how to proceed with their appointment and any potential coverage or reimbursement options.

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  • 11. 

    The QMB Program

    • A.

      Allows qualified individuals to have Medicaid pay for their Medicare premiums, deductibles, and coinsurance.

    • B.

      Allows qualified individuals to have Medicaid pay Medicare for Medicare Part B premiums.

    • C.

      Allows qualified individuals the option to enroll into Medicaid Managed Care Plans outside of their region.

    • D.

      Allows qualified individuals the option to hire a family member to help provide services in the home.

    Correct Answer
    A. Allows qualified individuals to have Medicaid pay for their Medicare premiums, deductibles, and coinsurance.
    Explanation
    The QMB Program allows qualified individuals to have Medicaid cover their Medicare premiums, deductibles, and coinsurance. This means that eligible individuals can receive financial assistance from Medicaid to help with the costs associated with their Medicare coverage.

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  • 12. 

    The SLMB Program

    • A.

      Allows qualified individuals to have Medicaid pay Medicare for Medicare Part B premiums.

    • B.

      Allows qualified individuals the option to enroll into Medicaid Managed Care Plans outside of their region.

    • C.

      Allows qualified individuals to have Medicaid pay for their Medicare premiums, deductibles, and coinsurance.

    • D.

      Allows qualified individuals the option to hire a family member to help provide services in the home.

    Correct Answer
    A. Allows qualified individuals to have Medicaid pay Medicare for Medicare Part B premiums.
    Explanation
    The SLMB Program allows qualified individuals to have Medicaid pay Medicare for Medicare Part B premiums. This means that individuals who meet the eligibility criteria can have their Medicare Part B premiums covered by Medicaid, reducing their out-of-pocket expenses. This program is beneficial for those who may struggle to afford the monthly premiums on their own.

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  • 13. 

    To complete a plan change from PACE into a LTC plan, the recipient must

    • A.

      Complete the plan change online.

    • B.

      Call SSA.

    • C.

      Call the Elder Helpline.

    • D.

      Call the SMMC line to request a plan change.

    Correct Answer
    C. Call the Elder Helpline.
    Explanation
    To complete a plan change from PACE into a LTC plan, the recipient must call the Elder Helpline. This suggests that the Elder Helpline is the appropriate channel to request a plan change in this specific scenario. It is likely that the Elder Helpline has the necessary resources and information to guide the recipient through the process of changing their plan. Calling SSA or the SMMC line may not be the correct option as they may not be directly involved in facilitating plan changes. Completing the plan change online is not mentioned as a requirement, indicating that calling the Elder Helpline is the preferred method.

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  • 14. 

    "My neighbor Sue helps me during the day.  She cooks for me and helps me around the house.  I really appreciate her help, but she will be going out of town for a week.  I won't have anyone to help me until she gets back." Which covered service is the recipient referring to?   

    • A.

      Assistive Care Services

    • B.

      Attendant Care

    • C.

      Homemaker Services

    • D.

      Personal Care

    Correct Answer
    C. Homemaker Services
    Explanation
    The recipient is referring to Homemaker Services. This is evident from the statement that Sue helps with cooking and helping around the house, which are tasks typically covered under Homemaker Services.

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  • 15. 

    What does the "T" shown for the recipient's LTC coverage mean ?

    • A.

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

    • B.

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

    • C.

      The recipient has experienced a temporary loss and will continue services at no charge for 60 days.

    • D.

      The recipient is not eligible to be enrolled into a LTC plan

    Correct Answer
    C. The recipient has experienced a temporary loss and will continue services at no charge for 60 days.
    Explanation
    The "T" shown for the recipient's LTC coverage means that the recipient has experienced a temporary loss and will continue to receive services at no charge for 60 days. This indicates that there may have been a disruption in the recipient's coverage, but they will still be able to receive services without having to pay for them for a certain period of time.

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  • 16. 

    A worker for the Department of Children and Families or Community Based Care calls. How do you proceed?

    • A.

      Inform the caller that you are not allowed to speak with any agencies and instruct them to have the member call back.

    • B.

      Document the callers Name, DOB, last 5 of SSN, and Certification or License Number and continue with the call.

    • C.

      Document the caller's Name, Agency & Title, Work Phone Number, Statement of Authority and continue with the call.

    Correct Answer
    C. Document the caller's Name, Agency & Title, Work Phone Number, Statement of Authority and continue with the call.
    Explanation
    The correct answer is to document the caller's Name, Agency & Title, Work Phone Number, Statement of Authority and continue with the call. This is the appropriate response because it allows for proper identification and verification of the caller's credentials. By documenting this information, it ensures that the worker can confirm the legitimacy of the caller and proceed with the call in a professional manner.

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  • 17. 

    If the CMS special condition expires,...

    • A.

      Then the child will have 60 days to continue to recieve services from CMS.

    • B.

      Then the child has been cured of the special condition.

    • C.

      Then the child can enroll into CMS.

    • D.

      Then the child will be disenrolled from CMS.

    Correct Answer
    D. Then 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.

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  • 18. 

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

    • A.

      Sunshine Health Child Welfare

    • B.

      Magellan Complete Care

    • C.

      Children's Medical Services

    • D.

      Positive Healthcare/Clear Health Alliance

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

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  • 19. 

    My name is Dr. Smith and I need to verify the Medicaid eligibility for Jon Doe.  Where do I call?

    • A.

      SSA

    • B.

      AHCA Medicaid Helpline

    • C.

      Provider Needs Eligibility Information

    • D.

      DCF

    Correct Answer
    C. Provider Needs Eligibility Information
    Explanation
    The correct answer is "Provider Needs Eligibility Information". This option is the most appropriate because Dr. Smith is looking to verify Medicaid eligibility for Jon Doe. Therefore, he would need to contact the Provider Needs Eligibility Information service to obtain the necessary information. The other options, SSA, AHCA Medicaid Helpline, and DCF, do not specifically address the need for eligibility verification.

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  • 20. 

    Why is the member listed below Excluded from enrolling into a LTC plan?

    • A.

      He is receiving Medicaid from the Social Security Administration.

    • B.

      He has ADP: IC meaning he is currently incarcerated.

    • C.

      His Medicaid ended on 5/1/2010.

    • D.

      He Is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities.

    Correct Answer
    D. He Is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities.
    Explanation
    The member is excluded from enrolling into a LTC plan because he is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities. This type of facility provides specialized care for individuals with developmental disabilities, and it is likely that the facility already provides the necessary long-term care services that would be covered by a LTC plan. Therefore, enrolling in a separate LTC plan would be redundant in this case.

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  • 21. 

    Why is the member below categorized as Voluntary under LTC?

    • A.

      She has (LTCC) indicator next to her Level of Care.

    • B.

      She has APD: WL meaning she is on the Agency for Persons with Disabilities Waitlist.

    • C.

      She has ( MWA ) ACWM.

    • D.

      She has APD: WL meaning she is on the Weight Loss Waiver Program.

    Correct Answer
    B. She has APD: WL meaning she is on the Agency for Persons with Disabilities Waitlist.
    Explanation
    The member below is categorized as Voluntary under LTC because she has APD: WL, which stands for Agency for Persons with Disabilities Waitlist. This indicates that she is on the waitlist for the Agency for Persons with Disabilities, suggesting that she voluntarily sought out their services. The other indicators, such as LTCC, MWA, and ACWM, do not directly relate to her categorization as Voluntary under LTC.

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  • 22. 

    For the LTC program, enrollees that are in a "temporary loss" period will

    • A.

      Have to start the enrollment process to be eligible for the LTC program all over.

    • B.

      Be responsible for paying the plan for services received during the temporary loss.

    • C.

      Continue receiving services from the LTC plan for up to 60 days and cannot change plans.

    • D.

      Have the option to change to a different LTC plan if they choose to.

    Correct Answer
    C. Continue receiving services from the LTC plan for up to 60 days and cannot change plans.
    Explanation
    During a "temporary loss" period in the LTC program, enrollees will continue to receive services from the LTC plan for a maximum of 60 days. However, they will not be able to change to a different LTC plan during this period.

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  • 23. 

    With Medicaid Pending

    • A.

      If the recipient is deemed not eligible for Medicaid, then they are not responsible for any services rendered and the managed care plan may terminate services and seek reimbursement.

    • B.

      The recipient cannnot change to a different managed care plan but can disenroll to discontinue services.

    • C.

      The recipient will have 60 days to obtain Medicaid eligibility.

    • D.

      Recipients that are in a nursing facility are also eligible to enroll under Medicaid Pending.

    Correct Answer
    B. The recipient cannnot change to a different managed care plan but can disenroll to discontinue services.
    Explanation
    If a recipient is enrolled in Medicaid Pending, they are not able to switch to a different managed care plan. However, they do have the option to disenroll from the current plan, which will result in discontinuation of services. This means that if the recipient is not eligible for Medicaid, they will not be responsible for any services rendered and the managed care plan may terminate services and seek reimbursement. Additionally, recipients who are in a nursing facility can still enroll under Medicaid Pending. The recipient will have a 60-day period to obtain Medicaid eligibility.

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  • 24. 

    For LTC, Pending Choice is when 

    • A.

      The recipient is not eligible and will receive services regardless of their Medicaid eligibility status.

    • B.

      The recipient can choose to enroll and not start services until Medicaid has been approved.

    • C.

      The recipient can receive services from the plan while their Medicaid eligibility is being determined.

    • D.

      The recipient is Medicaid eligible and is waiting to be approved for entry into the LTC program.

    Correct Answer
    B. The recipient can choose to enroll and not start services until Medicaid has been approved.
    Explanation
    The correct answer is when the recipient can choose to enroll and not start services until Medicaid has been approved. This means that the recipient has the option to sign up for the LTC program but can delay starting the services until their Medicaid eligibility has been confirmed.

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  • 25. 

    What does the CARES assessment do?

    • A.

      Identify long-term care needs, recommend the least restrictive, safe, and most appropriate placement and establish the appropriate Level of Care.

    • B.

      Assist with changing direct service providers and ensuring that licensing is up to date.

    • C.

      Screens members and provides information for the Participant Direction Option Program.

    • D.

      Establish Medicaid eligibility and provides counseling for other government funded programs.

    Correct Answer
    A. Identify long-term care needs, recommend the least restrictive, safe, and most appropriate placement and establish the appropriate Level of Care.
    Explanation
    The CARES assessment is designed to identify the long-term care needs of individuals and recommend the most suitable placement for them. It aims to find the least restrictive and safest environment for the person while ensuring that their care needs are met appropriately. Additionally, the assessment helps establish the appropriate Level of Care required for the individual.

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  • 26. 

    The Care Coordinator/Case manager will do all of the following EXCEPT:

    • A.

      Develop a plan of care.

    • B.

      Become the Power of Attorney and make changes to the recipients case.

    • C.

      Assist the enrollee in obtaining appropriate care.

    • D.

      Meet with the enrollee to perform an assessment.

    Correct Answer
    B. Become the Power of Attorney and make changes to the recipients case.
    Explanation
    The Care Coordinator/Case manager is responsible for developing a plan of care, assisting the enrollee in obtaining appropriate care, and meeting with the enrollee to perform an assessment. However, they do not have the authority to become the Power of Attorney and make changes to the recipient's case. This role is typically fulfilled by a legal representative or family member appointed as the Power of Attorney.

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  • 27. 

    Medicaid Pending enrollments are available to:

    • A.

      All recipients

    • B.

      HCBS individuals

    • C.

      Dual Eligibles

    • D.

      Recipients over 65

    Correct Answer
    B. HCBS individuals
    Explanation
    Medicaid Pending enrollments are available to HCBS individuals. HCBS stands for Home and Community Based Services, which are designed to provide long-term care services and support to individuals who prefer to receive assistance in their own homes or community settings rather than in institutions. This answer suggests that individuals who qualify for HCBS services can enroll in Medicaid while their application is still pending, allowing them to access the necessary care and support during the waiting period.

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  • 28. 

    When will the 120 day trial period start for Med Pending enrollments?

    • A.

      The 120 days will start after the initial lock-in period ends.

    • B.

      The 120 days will start on the first day of the month that eligibility is received.

    • C.

      The LTC recipients do not get 120 days to try out the plan because their special needs.

    • D.

      The 120 days will start after open enrollment to ensure that the member is satisfied.

    Correct Answer
    B. The 120 days will start on the first day of the month that eligibility is received.
    Explanation
    The correct answer is that the 120 days will start on the first day of the month that eligibility is received. This means that once a person becomes eligible for Med Pending enrollments, they will have 120 days from the beginning of the next month to try out the plan.

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  • 29. 

    If the caller states that the LTC plans are not providing them information about benefits, limits, service providers, extra services, cost sharing, etc., What should you do?

    • A.

      Tell the caller that the plans don't have to provide that information unless enrolled.

    • B.

      Tell the caller to call the Governor's office.

    • C.

      File a complaint.

    • D.

      Report the incident to Medicaid Fraud Hotline.

    Correct Answer
    C. File a complaint.
    Explanation
    If the caller states that the LTC plans are not providing them information about benefits, limits, service providers, extra services, cost sharing, etc., the appropriate action to take is to file a complaint. This is because the caller is not receiving the necessary information about their LTC plans, which is a violation of their rights. By filing a complaint, the issue can be addressed and resolved, ensuring that the caller receives the required information about their LTC plans.

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  • 30. 

    Can an OB/GYN doctor be a PCP?

    • A.

      No, they can never be a Primary Care Provider and a Specialist at the same time.

    • B.

      Yes, as long as the member states they see them for Primary care needs as well.

    • C.

      Yes, as long as they are listed as a Primary Care Provider.

    • D.

      Yes, because they are a doctor and can offer any medical services.

    Correct Answer
    C. Yes, as long as they are listed as a Primary Care Provider.
    Explanation
    An OB/GYN doctor can be a PCP as long as they are listed as a Primary Care Provider. This means that they are recognized and authorized to provide primary care services to patients. Being a specialist in obstetrics and gynecology does not exclude them from also serving as a PCP, as long as they have the necessary qualifications and are listed as such.

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  • 31. 

    Can you enroll this recipient with the PCP below?

    • A.

      Yes, if that is who the caller is requesting.

    • B.

      No, the recipient does not meet the age restrictions of the provider.

    • C.

      Yes, if the recipient is in Broward County.

    • D.

      No, because the provider is in Fort Lauderdale.

    Correct Answer
    B. No, the recipient does not meet the age restrictions of the provider.
    Explanation
    The correct answer is "No, the recipient does not meet the age restrictions of the provider." This means that the recipient cannot be enrolled with the PCP mentioned because they do not meet the age requirements set by the provider.

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  • 32. 

    Rosa calls to make a plan change for her daughter Ashley. Rosa does not have the PIN number listed on the case. How do you proceed? 

    • A.

      Tell Rosa that she is not the authorized person on the case because Ashley is an adult and you cannot continue with the call.

    • B.

      Advise Rosa to look through her mail for the PIN number and to give us a call back once she finds it.

    • C.

      Refer Rosa to AHCA to request that another PIN number be sent to her because someone may have taken it.

    • D.

      Ask Rosa whether she has authority to obtain information or make changes for the person she is calling for and continue with normal verification procedure.

    Correct Answer
    D. Ask Rosa whether she has authority to obtain information or make changes for the person she is calling for and continue with normal verification procedure.
    Explanation
    The correct answer is to ask Rosa whether she has authority to obtain information or make changes for the person she is calling for and continue with normal verification procedure. This is the appropriate response because it allows Rosa the opportunity to confirm her authorization to make changes for her daughter, Ashley. By proceeding with the normal verification procedure, the representative can ensure that the person on the call has the necessary authority to make changes or obtain information.

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  • 33. 

    Roger Guiness is calling to enroll mother Alice Munro. He is listed in the physical address field with C/O (in care of) for his mother. Which of the following statements below is true?

    • A.

      Roger is automatically authorized because he is listed in the C/O field.

    • B.

      Roger is still required to pass verification in order to determine if he is authorized on the case.

    • C.

      Roger is authorized because he is Alice's son.

    • D.

      Roger's mother Alice must be present to verify the information in order for the call to continue.

    Correct Answer
    B. Roger is still required to pass verification in order to determine if he is authorized on the case.
    Explanation
    The fact that Roger is listed in the physical address field with C/O (in care of) for his mother does not automatically authorize him. He still needs to pass verification to determine if he is authorized on the case.

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  • 34. 

    Caller states:  "I was informed that my specialist doesn't accept my new plan. I've been in this plan for less than 60 days. The specialist accepted my old plan when I scheduled an appointment 3 months ago. I cannot reschedule because it takes too long to get an appointment with this specialist." How should you proceed?   

    • A.

      Tell the caller the appointment needs to be cancelled and re-scheduled with the new plan.

    • B.

      Explain Continuity of Care and refer to the current plan for more information.

    • C.

      Tell the caller that AHCA will not cover previously scheduled appoints since the provider doesn't accept the plan.

    • D.

      Tell the caller the appointment will not be covered because the provider is not part of the plan's network.

    Correct Answer
    B. Explain Continuity of Care and refer to the current plan for more information.
    Explanation
    Continuity of Care is a concept that ensures patients can continue receiving care from their current healthcare provider even if there are changes in their insurance plan. In this case, the caller has been seeing a specialist who accepted their old plan and now they have switched to a new plan. Since the caller has been in the new plan for less than 60 days and it takes a long time to get an appointment with this specialist, it is important to explain Continuity of Care to the caller. This will help them understand that they may still be able to see the specialist and provide them with information on how to proceed with their current plan.

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  • 35. 

    When does Continuity of Care apply?

    • A.

      When a recipient changes from one plan to another plan.

    • B.

      When a recipient changes from Fee-For-Service to a MMA plan.

    • C.

      When a recipient changes from a LTC plan to private insurance.

    • D.

      When a recipient changes plans and needs to schedule an appointment.

    Correct Answer
    A. When a recipient changes from one plan to another plan.
    Explanation
    Continuity of Care applies when a recipient changes from one plan to another plan. This means that when a recipient switches from one healthcare plan to another, they are entitled to continue receiving the same level of care and services without interruption. This ensures that the recipient's healthcare needs are met and that there is a smooth transition between plans.

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  • 36. 

    Special Condition spans ‘LTC Non-COMP’ and ‘SMMC COMP Enrolled' are added as a member's special condition based on____________.

    • A.

      Level of Care

    • B.

      MMA Eligibility

    • C.

      LTC or Comprehensive enrollments.

    • D.

      LTC Eligibility

    Correct Answer
    C. LTC or Comprehensive enrollments.
    Explanation
    The correct answer is "LTC or Comprehensive enrollments." This means that the special conditions "LTC Non-COMP" and "SMMC COMP Enrolled" are added to a member's profile if they have either a long-term care (LTC) enrollment or a comprehensive enrollment. This suggests that these special conditions are specifically related to the type of enrollment the member has, whether it is for long-term care or comprehensive coverage.

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  • 37. 

    Jeremy Spencer is calling to enroll himself into United Healthcare of Florida. Is the agent still required to ask him if he has authority or permission to obtain information or make changes for himself?

    • A.

      Yes, because if the agent skips the question, it will result in a prohibited activity.

    • B.

      Yes, because all callers must state they have authority to make changes or obtain information for the person(s) they are calling for, even if they are calling for themselves.

    • C.

      Yes, because AHCA requires that all callers answer that question.

    • D.

      No, the agent may skip the authorization question if they are calling for themselves.

    Correct Answer
    D. No, the agent may skip the authorization question if they are calling for themselves.
    Explanation
    The correct answer is "No, the agent may skip the authorization question if they are calling for themselves." This is because if someone is calling for themselves, they already have the authority and permission to obtain information or make changes for themselves. Therefore, it is not necessary for the agent to ask them if they have authority or permission.

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  • 38. 

    Anthony Wolf is complaining against AHCA because they are refusing to pay for his bariatric surgery under Fee-For-Service Medicaid and he depends on that procedure to survive. What Issue Severity applies? 

    • A.

      Medium: the recipient is unable to reach a resolution with a health plan or provider regarding desired services/Dissatisfied with available plan/provider services.

    • B.

      High: describes dissatisfaction with a medical issue that may be detrimental to the recipients health.

    • C.

      Low: recipient is unable to reach a health plan and/or provider to schedule an appointment/Dissatisfied with the available plan and/or PCP options.

    • D.

      Do not file a complaint and advise the member to go to the emergency room.

    Correct Answer
    B. High: describes dissatisfaction with a medical issue that may be detrimental to the recipients health.
    Explanation
    The correct answer is High: describes dissatisfaction with a medical issue that may be detrimental to the recipient's health. This is because Anthony Wolf is complaining about AHCA refusing to pay for his bariatric surgery, which he depends on for survival. This dissatisfaction with the denial of a necessary medical procedure can potentially have a negative impact on the recipient's health.

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  • 39. 

    To remove  HIV/AIDS, SMI, or Freedom special conditions from a recipients case, the agent should:

    • A.

      Inform the caller that we do not update special conditions and file a complaint in the complaint wizard.

    • B.

      Submit a task to a supervisor to inform them that you need approval to contact AHCA for the member.

    • C.

      Contact the SNU, explain the members situation and the request that the special condition be removed.

    • D.

      Select MC EX/SC in Health Track, click on the special condition box and submit the request.

    Correct Answer
    D. Select MC EX/SC in Health Track, click on the special condition box and submit the request.
    Explanation
    The correct answer is to select MC EX/SC in Health Track, click on the special condition box, and submit the request. This option is the most appropriate because it directly addresses the issue of removing special conditions from a recipient's case. By selecting MC EX/SC in Health Track and submitting the request, the agent can initiate the necessary steps to remove the special condition. The other options mentioned in the question do not specifically address the removal of special conditions or may not be the most effective course of action in this situation.

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  • 40. 

    Caller states: "I went to the pharmacy to pick up my seizure medication and they told me I had to pay out of pocket because my new plan would not cover it. It's too expensive, I can't pay for it! That's the reason I'm on Medicaid! I need my medicine!" How should you proceed?

    • A.

      Explain continuity of care and tell the caller to call the new plan and provide them with prescription information.

    • B.

      Tell the caller they will have to pay out of pocket for prescription refills and refer to the AHCA Medicaid Helpline to complain.

    • C.

      Advised the caller that there is nothing we can do and provide the open enrollment period dates.

    • D.

      Tell the caller they can contact their plan case manager to use Expanded Benefits to pay for the prescriptions.

    Correct Answer
    A. Explain continuity of care and tell the caller to call the new plan and provide them with prescription information.
    Explanation
    The correct answer is to explain continuity of care and tell the caller to call the new plan and provide them with prescription information. This is the best course of action because it addresses the caller's concern about not being able to afford their medication and provides a potential solution by contacting the new plan. Explaining continuity of care also helps the caller understand the importance of maintaining their medication regimen and seeking assistance from their new plan.

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  • 41. 

    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.   Flora wants to know what kind of Medicaid she has and what she needs to do about health coverage. What information should be provided to Flora?

    • A.

      Tell Flora, she can't choose a plan, refer her to DCF and discontinue the call.

    • B.

      Advise Flora that Medicare is her primary insurance and she has limited Medicaid coverage that picks up some of the out of pocket expenses from Medicare.

    • C.

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

    • D.

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

    Correct Answer
    B. Advise Flora that Medicare is her primary insurance and she has limited Medicaid coverage that picks up some of the out of pocket expenses from Medicare.
    Explanation
    The correct answer is to advise Flora that Medicare is her primary insurance and she has limited Medicaid coverage that picks up some of the out of pocket expenses from Medicare. This means that Flora cannot choose a separate plan for Medicaid coverage, but Medicaid will help cover some of the costs that Medicare does not.

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  • 42. 

    According to the eligibility information in the hover, this recipient would be  __________ for MMA enrollment. 

    • A.

      Mandatory

    • B.

      Voluntary

    • C.

      Excluded

    Correct Answer
    C. Excluded
    Explanation
    Based on the given information, the recipient would be excluded for MMA enrollment.

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  • 43. 

    Paul wants to know who is going to cover his services. He states that he has Medicare and is enrolled in a MMA plan. How should you proceed? 

    • A.

      Advise Paul that the MMA plan is responsible for coordinating the member's care with Medicare and ensuring that the MMA plan does not authorize or provide duplicative services. Then refer him to the MMA plan's case manager.

    • B.

      Refer Paul to AHCA for help with determining which insurance is going to cover their services.

    • C.

      Advise Paul to let the providers figure it out and bill him because Medicaid will pay the remaining balance.

    • D.

      Refer Paul to Medicare to determine what they don't cover and compare it to what the MMA plan covers.

    Correct Answer
    A. Advise Paul that the MMA plan is responsible for coordinating the member's care with Medicare and ensuring that the MMA plan does not authorize or provide duplicative services. Then refer him to the MMA plan's case manager.
    Explanation
    The correct answer is to advise Paul that the MMA plan is responsible for coordinating his care with Medicare and ensuring that the MMA plan does not authorize or provide duplicative services. This is the appropriate course of action because MMA plans are designed to work in conjunction with Medicare, and the MMA plan's case manager can provide further assistance and guidance in determining coverage for Paul's services.

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  • 44. 

    Susan has Medicare and Medicaid.  She wants to know which MMA plan is affiliated with her Medicare plan.  How should you proceed?

    • A.

      Refer Susan to Medicare to find out which MMA plan is affiliated with her Medicare plan.

    • B.

      Advise Susan of the MMA plan that sounds similar to the name of the Medicare plan she has.

    • C.

      Refer Susan to the AHCA Medicaid Helpline to verify the services that the MMA plan is going to cover.

    • D.

      Advise Susan to contact the Social Security Administration to obtain a list of MMA plans affiliated with Medicare plans.

    Correct Answer
    A. Refer Susan to Medicare to find out which MMA plan is affiliated with her Medicare plan.
    Explanation
    The correct answer is to refer Susan to Medicare to find out which MMA plan is affiliated with her Medicare plan. This is the best course of action because Medicare would have the most accurate and up-to-date information regarding the affiliation between Medicare and MMA plans. Medicare would be able to provide Susan with the specific details she needs to determine which MMA plan is affiliated with her Medicare plan.

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  • 45. 

    How was this member enrolled into their health plan? 

    • A.

      Member called and voluntarily enrolled.

    • B.

      Member was auto assigned by Health Track.

    • C.

      Member enrolled through the IVR.

    • D.

      Member enrolled online.

    Correct Answer
    B. Member was auto assigned by Health Track.
    Explanation
    The correct answer is "Member was auto assigned by Health Track." This means that the member did not voluntarily enroll themselves into the health plan. Instead, Health Track automatically assigned them to the plan, possibly based on certain criteria or eligibility requirements.

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  • 46. 

    How did the member enroll? 

    • A.

      The member enrolled by mail.

    • B.

      The member called the call center.

    • C.

      The member was auto assigned.

    • D.

      The member completed an express enrollment.

    Correct Answer
    D. The member completed an express enrollment.
    Explanation
    The correct answer is "The member completed an express enrollment." This means that the member enrolled by completing an express enrollment process. This could involve filling out an online form or providing necessary information over the phone to quickly enroll in the program or service.

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  • 47. 

    Why is the member excluded from enrolling in LTC?

    • A.

      The member cannot enroll in LTC because she is pregnant.

    • B.

      The member cannot enroll in LTC because she does not have a level of care.

    • C.

      The member cannot enroll in LTC because her ACWM is MMP and she can only get services for her pregnancy.

    • D.

      HealthTrack is incorrect. The member should be able to enroll in LTC because they have a Medicaid application and she meets the age criteria.

    Correct Answer
    B. The member cannot enroll in LTC because she does not have a level of care.
    Explanation
    The correct answer is that the member cannot enroll in LTC because she does not have a level of care. This means that she does not meet the criteria or requirements for receiving long-term care services. It is not mentioned in the given information that the member is pregnant or that she has a Medicaid application. Therefore, these factors are not relevant to the explanation.

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  • 48. 

    The member needs to update her address, where should you refer?

    • A.

      DCF

    • B.

      SSA

    • C.

      AHCA

    • D.

      Health Plan

    Correct Answer
    B. SSA
    Explanation
    The member needs to update her address, so the appropriate place to refer her would be the Social Security Administration (SSA). The SSA is responsible for maintaining records and information related to Social Security benefits, including personal information such as addresses. Therefore, they would be the most suitable entity to handle address updates for the member.

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  • 49. 

    What does the 'R' mean?

    • A.

      The member can receive services for up to 60 days without eligibility.

    • B.

      The member has recertified with DCF and can start receiving services now.

    • C.

      The member is Medicaid eligible and will be enrolled into the previous plan.

    • D.

      If the member gains full eligibility within 6 months, they may be enrolled in the same plan they had previously (if available).

    Correct Answer
    D. If the member gains full eligibility within 6 months, they may be enrolled in the same plan they had previously (if available).
    Explanation
    The 'R' in this context refers to the member being able to be enrolled in the same plan they had previously, if they gain full eligibility within 6 months. This means that if the member's eligibility status changes and they become fully eligible for Medicaid within 6 months, they have the opportunity to continue receiving services under the same plan they were enrolled in before, if that plan is still available.

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  • 50. 

    Marisol is calling for her daughter Anamaris, she does not have the PIN number, how do you proceed?

    • A.

      Tell Marisol to send the DAR form, provide her with the fax number and continue with verification.

    • B.

      Tell Marisol that she must have the pin number when calling for another adult and do not continue the call.

    • C.

      Marisol is authorized because she is the parent of Anamaris and because she is listed on the same case.

    • D.

      Tell Marisol that she must call DCF for a confidentiality code to be authorized to access her daughter's case

    Correct Answer
    A. Tell Marisol to send the DAR form, provide her with the fax number and continue with verification.
    Explanation
    Marisol is calling for her daughter Anamaris, but she does not have the PIN number. In this situation, the correct approach is to tell Marisol to send the DAR form and provide her with the fax number. This is because the DAR form allows Marisol to verify her identity and establish her authorization to access her daughter's case. By providing the fax number, Marisol can send the necessary documents for verification, ensuring the security and confidentiality of the information. Continuing with the verification process after receiving the DAR form is the appropriate course of action.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 20, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Dec 31, 2013
    Quiz Created by
    AHSFLTrainer
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