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 Center's 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.
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.
Sunshine Health Child Welfare
Magellan Complete Care
Children's Medical Services
Positive Healthcare/Clear Health Alliance
No, they are currently in a no change period.
Yes, they qualify for a Good Cause plan change.
No, they are a mandatory member and must keep current plan.
Yes, they are currently in their 120 day change period.
Change to another LTC plan.
Inform the recipient they are not eligible to make a plan change because they are eligible for PACE.
Remain in Sunshine Health or disenroll from Sunshine and wait to receive services once Medicaid is approved.
Refer the recipient to DOEA to get an exemption because LTC recipients do not make plan changes without exemptions.
Refer to DOEA.
Refer to the LTC plan.
Refer to AHCA.
Refer to the MMA plan.
They are not eligible to make a plan change because they are currently in a Nursing Home.
Can change plan to PACE only.
Can change into another available LTC plan.
They must keep the current American Eldercare plan.
Information for Children on the case
All of the previous case numbers for the member if they have switched cases.
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 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.
Inform the recipient they cannot enroll into a plan because of the demise date of 12/15/2012 on file.
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 APD and exemption and can only have FFS.
Inform the recipient they cannot enroll into a plan because there is an exemption on the case. Refer the recipient to DCF to have the date of demise removed.
Recipient is receiving Medicaid from the Social Security Administration.
Recipient has APD: IC meaning they are currently incarcerated.
Medicaid ended on 5/1/2010.
Recipient is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities.
She has (LTCC) indicator next to her level of care.
She has APD: WL meaning she is on the Agency for Persons with Disabilities Waitlist.
She has (MWA) ACWM.
She has APD: WL meaning she is on the Weight Loss Waiver Program.
The recipient's LTC coverage has been terminated and they are no longer receiving services.
The recipient experienced a temporary loss and must pay for services until coverage is reinstated.
The recipient has experienced a temporary loss and will continue to receive services at no charge for 60 days.
The recipient is not eligible to be enrolled into a LTC plan.
Yes, this recipient must be enrolled into a managed care plan.
No, only recipient 18 and over can enroll into a Managed Medical Assistance plan
No, this recipient has an exemption.
No, this recipient's Medicaid coverage ended on 1/1/2006.
Refer the caller to DCF/SSA because they are not eligible yet.
Do not ask questions and automatically transfer to extension 2042.
Follow the script to determine if the member needs to be transferred to Express Enrollment.
Advise the member to allow 24-48 business hours for their eligibility to update and call back.
The member will use FFS Medicaid to get services. Medicaid is primary and the private insurance is secondary.
The Member has QMB, it is not full Medicaid coverage. It covers Medicare premiums, deductibles and coinsurance. The member also has a Medicare Special Needs plan (TPL 11) that will cover services.
The member has Share of Cost. Medicaid will pay any service that is not covered by Medicare.
The member has a Special Needs Plan that will cover 80% of services and QMB will cover the other 20% for doctor's visits and prescriptions.
Refer to the plan
Assist the caller with what they need
Refer to the MediKids Helpline
Refer to KidCare
The member is enrolled in PACE and will receive medical and long-term care services from PACE.
The member has a TPL on file and will receive all services through the private insurance.
The member receives Medicaid through the SSA and is disabled, so they can use FFS Medicaid.
It is an error, the member qualifies to enroll in LTC and MMA.
Submit a MC Exemption request to AHCA because the recipient wants straight Medicaid.
File a complaint against AHCA. Florida statute states recipients 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. Tell the caller when the plan can be changed and refer to the plan if the caller is having difficulty seeing providers or receiving services.
Recipients that receive Supplemental Security Income
Recipients with APD
Recipients with Medicare
Recipients that are in foster care
Then the child will have 60 days to continue to recieve 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.
Tell Flora, she can't choose a plan and discontinue the call.
Submit a discrepancy log to request for Flora to be enrolled into a plan.
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.
Advise Flora that she can't pick a plan because she has FFS.
Serious Mental Illness
Here's an interesting quiz for you.