2018 Fl Smmc Good Cause Quiz

The enrollee's statement suggests that they have been placed in a plan without their consent and that their preferred doctor does not accept the plan. GC9 would apply in this situation as it allows for a plan change if the enrollee's provider network changes and their current doctor is no longer in-network.

The correct answer is GC17. This is because the enrollee has a specific medical condition, HIV, and their doctor has recommended a change to a specific health plan, Clear Health Alliance / Positive HealthCare, in order to access the necessary specialists. GC17 allows for plan changes when a specific health condition requires a specific health plan.

When an enrollee has an issue with their plan, the first step they should take is to contact the plan for a resolution. This is the most direct and efficient way to address any concerns or problems with the plan. Filing a complaint through the AHCA Medicaid Helpline or contacting the SMMC Helpline to see if they qualify for a GC plan change may be necessary if the issue is not resolved by contacting the plan directly. Writing a bad review of the plan online is not a productive or effective way to seek a resolution to the issue.

The enrollee does not qualify for a Good Cause plan change at this time because forgetting to call to change the plan is not considered a valid reason for a Good Cause plan change. Good Cause plan changes typically involve specific circumstances such as a change in income, loss of other health coverage, or a move to a new service area. Forgetting to make a plan change or wanting to change the plan based on someone else's opinion does not meet the criteria for a Good Cause plan change.

The enrollee can use GC7 as the Good Cause to change her plan. GC7 allows enrollees to change their plan if they have a problem with the quality of care they are receiving, including concerns about the doctor not having the best interest of the patient in mind. Since the enrollee feels that the doctor is not providing the best care for her aunt, she can use GC7 to switch to a different plan that better meets her needs and ensures her aunt's well-being.

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The explanation for the correct answer is that HealthTrack requires enrollees to receive a written response to their grievance before allowing them to make a Good Cause plan change. This means that if an enrollee has a complaint or concern, they must go through the grievance process and receive a written response before they can proceed with changing their plan for a valid reason. Therefore, the statement is true.

The correct answer is to contact SNU to see if a SNU transfer is required for situations that may be serious or life-threatening. This is because the enrollee's situation is urgent and they need immediate medical attention. SNU (Special Needs Unit) is responsible for handling cases that require special attention or urgent care. By contacting SNU, the enrollee can be transferred to a plan that covers the necessary kidney transplant surgery.

GC1621 is the correct answer because it allows for a plan change if the enrollee's current provider is not within a reasonable distance or travel time. In this case, the enrollee states that the only doctor that takes their plan is over an hour away, and they cannot afford to keep going to them because it's too far away. This situation meets the criteria for GC1621, as it involves a significant distance and financial burden for the enrollee to access their current provider. Therefore, they would be eligible to change their plan in order to see a provider closer to them.

The correct answer is to advise the enrollee to wait for a response from the Agency for Healthcare Administration and not process an additional GC plan change. This is the appropriate course of action because a GC9 plan change has already been processed recently and the enrollee has not received a response yet. It is important to wait for the response from the Agency before taking any further action. In case of emergencies, the enrollee should be referred to AHCA for immediate assistance.

The GC17 option will not show because the HIV special condition must be on file for it to appear in the drop-down menu. The enrollee should be advised to fax in documentation of their HIV diagnosis and provided with the fax number for additional assistance.

The statement is false because not all Good Cause plan changes need to be approved by the Agency for Healthcare Administration. There may be certain changes that can be made without requiring approval from the agency.

This answer is correct because it accurately describes what a state approved Good Cause reason allows an enrollee to do. It states that it allows an enrollee to request a plan change when they are outside of their open enrollment period and locked-in to their plan. This means that even if the enrollee is not in the open enrollment period and is currently locked-in to their plan, they can still request a change if they have a Good Cause reason.

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The enrollee is experiencing a situation where they have three knee procedures that need to be done consecutively, but their plan will only cover two of them. If all three procedures are not completed within a certain timeframe, the enrollee believes they may be worse off than before. This situation aligns with Good Cause Reason GC14, which allows for a plan change due to a significant reduction in benefits.

GC1623 would apply in this situation. This GC allows an enrollee to change their plan if they have a specialized medical condition and the current plan does not cover the necessary treatment or services. Since the enrollee has an eye disease and needs a cornea transplant, and the only eye surgeon in their area who can perform the surgery does not accept their current plan, they would qualify for a plan change under GC1623.

The statement is false because not all Good Cause plan changes will be approved regardless of the reason. The approval of plan changes depends on various factors such as the validity and legitimacy of the reason provided for the change. Therefore, it is incorrect to say that all Good Cause plan changes will be approved without considering the reason.

The Good Cause Reason that can be used in this situation is GC4. GC4 refers to "Inadequate access to covered benefits." The enrollee is expressing frustration with the long wait times to see their doctor, indicating that they are experiencing inadequate access to the covered benefits of their plan. This would qualify them for a Good Cause plan change.

After an enrollee is approved for a Good Cause plan change, they will be granted an additional 120 day change period. This means that they will have 120 days to make any further changes to their plan if needed. This allows the enrollee more flexibility and time to adjust their plan according to their specific needs and circumstances.

The correct answer is to advise the enrollee of their lock-in and open enrollment dates and tell them to call back to change when they are in their open enrollment period. This is the appropriate response because open enrollment is the designated time for individuals to make changes to their healthcare plans. By informing the enrollee of their options and offering to file a complaint, the representative is providing assistance while following the proper procedures.