2018 Fl Smmc Good Cause Quiz

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2018 Fl Smmc Good Cause Quiz - Quiz

Good Cause Quiz


Questions and Answers
  • 1. 

    The enrollee is locked in and says: "I never picked this plan! You all put me in it! My doctor, that I really like, doesn't take this plan and has never taken it!  I've been with the same doctor for years, I don't want to change."  Which GC would apply?

    • A.

      • GC4

    • B.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • C.

      • GC1623

    • D.

      • GC9

    Correct Answer
    D. • GC9
    Explanation
    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.

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  • 2. 

    The enrollee is locked in and says: "I have HIV and my doctor told me to change to Clear Health Alliance / Positive HealthCare. I need that to start soon because all of my new specialists take that plan." Which GC would apply?

    • A.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • B.

      • GC9

    • C.

      • GC17

    • D.

      • GC7

    Correct Answer
    C. • GC17
    Explanation
    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.

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  • 3. 

    When the enrollee has an issue with their plan, what should they do first?

    • A.

      • File a complaint through the AHCA Medicaid Helpline.

    • B.

      • Contact the plan for a resolution.

    • C.

      • Write a bad review of the plan online.

    • D.

      • Contact the SMMC Helpline to see if they qualify for a GC plan change.

    Correct Answer
    B. • Contact the plan for a resolution.
    Explanation
    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.

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  • 4. 

    The enrollee is locked in and says: "Medicaid sent me a letter a while back with my open enrollment dates, but I forgot to call you to change my plan. I think the last day was last Thursday. I just want to change it because my sister said her plan was better than mine."  Which GC would apply?

    • A.

      • GC4

    • B.

      • GC1621

    • C.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • D.

      • GC7

    Correct Answer
    C. • The enrollee does not qualify for a Good Cause plan change at this time.
    Explanation
    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.

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  • 5. 

    The enrollee is locked in and says: "I am my aunt's caregiver and I am responsible for her healthcare decisions because she has Alzheimers. During a recent visit to her doctor, they refused to let me stay in the room during her procedure and did not let me make decisions on what treatments she should receive in the future. I know my aunt and her condition but I don't feel this doctor has her best interest in mind. Can I change her plan?" Which Good Cause would you use?

    • A.

      • GC1621

    • B.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • C.

      • GC4

    • D.

      • GC7

    Correct Answer
    D. • GC7
    Explanation
    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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  • 6. 

    If the enrollee has not completed the grievance/appeal process, the GC will be denied. How should you proceed in HealthTrack?

    • A.

      • Since the GC will be denied anyways, cancel the GC plan change.

    • B.

      • File a complaint through the AHCA Medicaid Helpline against the GC process.

    • C.

      • Place the plan change request in the discrepancy log because the enrollee may have a special medical need and really needs to change the plan.

    • D.

      • Complete all possible GC steps in HealthTrack and submit the GC so a denial letter will be mailed out.

    Correct Answer
    D. • Complete all possible GC steps in HealthTrack and submit the GC so a denial letter will be mailed out.
  • 7. 

    An enrollee has to receive a written response to the grievance before HealthTrack will allow the Good Cause plan change to be processed.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    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.

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  • 8. 

    1. The enrollee is locked in and says:  "I just got notified that I am a candidate for a kidney transplant.  I need to change the plan because the surgeon doesn't take my plan.  They want to schedule the surgery ASAP because my kidneys are not working and the dialysis treatment is not working anymore. The last time I called, you all told me I had to do some complaint process, but I just don't have time for that. I need the plan changed ASAP!" How should you proceed?

    • A.

      • Advise the enrollee to contact the AHCA Medicaid Helpline to see if they can process the plan change since it is an emergency.

    • B.

      • Blind transfer the enrollee to the escalation line so a Supervisor can be the one to tell the enrollee they do not qualify for a GC.

    • C.

      • Advise the enrollee that the grievance/appeal process must be completed to file a GC plan change.

    • D.

      • Contact SNU to see if a SNU transfer is required for situations that may be serious or life-threatening.

    Correct Answer
    D. • Contact SNU to see if a SNU transfer is required for situations that may be serious or life-threatening.
    Explanation
    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.

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  • 9. 

    The enrollee is locked in and says: "The only doctor that takes my plan is over an hour away, and I can't afford to keep going to them because it's too far away. Can I change my plan so I can see a provider closer to me?" Which Good Cause Reason can you use?

    • A.

      • GC4

    • B.

      • GC1621

    • C.

      • GC1623

    • D.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    Correct Answer
    B. • GC1621
    Explanation
    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.

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  • 10. 

    The enrollee is locked in and wants to process a GC plan change because their PCP does not take their current plan. When accessing the case to attempt a GC9, you see a GC9 has already been processed recently and the enrollee states they have not received a response. How should you proceed?

    • A.

      • Refer the enrollee to the DCF to check on the status of the GC plan change.

    • B.

      • Place the plan change request in the discrepancy log so that the GC9 can be addressed by an offline/resource desk agent.

    • C.

      • Advise the enrollee to wait for a response from the Agency for Healthcare Administration and do not process an additional GC plan change. Refer to AHCA for emergencies.

    • D.

      • Advise the enrollee that if they have not received a response it means the GC9 plan change request was denied. Offer to file a complaint.

    Correct Answer
    C. • Advise the enrollee to wait for a response from the Agency for Healthcare Administration and do not process an additional GC plan change. Refer to AHCA for emergencies.
    Explanation
    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.

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  • 11. 

    The enrollee states that they have recently been diagnosed with HIV and they want to enroll into Clear Health Alliance. Health track shows that they are locked in and the special condition is not on file. Why doesn't the GC17- Move to Specialty Plan show as an option in the drop down menu?

    • A.

      • The GC17 option will not show because the enrollee does not actually have HIV. Inform the enrollee of their lock-in and open enrollment dates.

    • B.

      • The HIV special condition must be on file for GC17 to show as an option in the drop down menu. Advise the enrollee to fax in documentation of the condition and provide the fax number for additional assistance.

    • C.

      • There is a system error in which the HIV special condition does not always show in HealthTrack. Place the GC17 request on the discrepancy log and advise the enrollee the plan change will be effective the first of the following month.

    • D.

      • The GC17 option will not show because HIV is no longer a special condition and there is no specialty plan for HIV.

    Correct Answer
    B. • The HIV special condition must be on file for GC17 to show as an option in the drop down menu. Advise the enrollee to fax in documentation of the condition and provide the fax number for additional assistance.
    Explanation
    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.

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  • 12. 

    All Good Cause plan changes must be approved by the Agency for Healthcare Administration.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    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.

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  • 13. 

    A state approved Good Cause reason...

    • A.

      • Allows an enrollee to request a plan change when they are outside of their open enrollment period and locked-in to their plan.

    • B.

      • Allows an enrollee to change the plan for any reason.

    • C.

      • Is a process used to issue denial letters to enrollees since you can't change the plan during the lock-in period.

    • D.

      • Allows the enrollee to opt out of the SMMC program and continue to receive services through FFS.

    Correct Answer
    A. • Allows an enrollee to request a plan change when they are outside of their open enrollment period and locked-in to their plan.
    Explanation
    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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  • 14. 

    The enrollee is locked in and says: "My plan has changed my primary care provider five times in the past few months. I just want to get comfortable with one provider and when I ask them why I am being changed, they won't give me an answer! Can I change my plan? Which Good Cause Reason can you use?

    • A.

      • GC4

    • B.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • C.

      • GC9

    • D.

      • GC1620

    Correct Answer
    D. • GC1620
  • 15. 

    The enrollee is locked in and says: "I have three knee procedures that need to be done back to back, but my plan will only cover two of them. If all three procedures aren't done within a certain amount of time, I may be worse off than when I started!" Which Good Cause Reason can you use?

    • A.

      • GC14

    • B.

      • GC4

    • C.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • D.

      • GC7

    Correct Answer
    A. • GC14
    Explanation
    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.

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  • 16. 

    The enrollee is locked in and says: "I have an eye disease and need a cornea transplant. I found one eye surgeon in my area but he doesn't take my plan. He's the only one in the area that knows how to do this surgery. Can I change my plan?"  Which GC would apply?

    • A.

      • GC9

    • B.

      • GC1623

    • C.

      • GC7

    • D.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    Correct Answer
    B. • GC1623
    Explanation
    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.

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  • 17. 

    All Good Cause plan changes will be approved regardless of the reason.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    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.

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  • 18. 

    The enrollee is locked in and says: "Whenever I try to go to an appointment with my doctor it takes forever to be seen! This is the only provider in the area that accepts my plan. Can I change my plan?" Which Good Cause Reason can you use?

    • A.

      • GC4

    • B.

      • GC9

    • C.

      • The enrollee does not qualify for a Good Cause plan change at this time.

    • D.

      • GC1621

    Correct Answer
    A. • GC4
    Explanation
    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.

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  • 19. 

    What happens after an enrollee is approved for a Good Cause plan change?

    • A.

      • An additional 60 day change period will be granted.

    • B.

      • An additional 120 day change period will be granted.

    • C.

      • The enrollee will be locked in to the new plan.

    • D.

      • An additional 90 day change period will be granted.

    Correct Answer
    B. • An additional 120 day change period will be granted.
    Explanation
    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.

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  • 20. 

    An enrollee is really upset and states they have received a denial letter from an attempted GC9 plan change. Their provider stopped accepting the plan and the enrollee does not want to change providers because this provider has all of their medical information and they are comfortable with them. How should you proceed?

    • A.

      • 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. Offer to file a complaint and include detailed notes.

    • B.

      • Submit the plan change request in the discrepancy log since the enrollee has a good reason to change the plan.

    • C.

      • Process another GC9 plan change and add that the enrollee is terminally ill so the request will not be denied.

    • D.

      • Refer the caller to DCF to find out why the GC9 was denied since it's not the caller's fault the PCP is not taking the plan anymore.

    Correct Answer
    A. • 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. Offer to file a complaint and include detailed notes.
    Explanation
    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.

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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
  • Sep 20, 2017
    Quiz Created by
    AHSFLTrainer
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