2018 Fl Smmc Good Cause Quiz

20 Questions | Total Attempts: 153

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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

  • 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

  • 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.

  • 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

  • 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

  • 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.

  • 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

  • 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.

  • 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.

  • 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.

  • 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.

  • 12. 
    All Good Cause plan changes must be approved by the Agency for Healthcare Administration.
    • A. 

      True

    • B. 

      False

  • 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.

  • 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

  • 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

  • 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.

  • 17. 
    All Good Cause plan changes will be approved regardless of the reason.
    • A. 

      True

    • B. 

      False

  • 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

  • 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.

  • 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.

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