2018 Fl Smmc Healthtrack Enrollee Information Quiz
This quiz assesses understanding of Florida's Statewide Medicaid Managed Care (SMMC) enrollment processes, including plan changes, exemptions, and eligibility categories. It is crucial for those managing or enrolling in Medicaid plans.
- 1.
The enrollee states they are new to Medicaid and wants to make a plan change because their PCP doesn't accept their current plan. When reviewing their case you see they just received Medicaid eligibility 8/1/2017, and the plan just became effective 9/1/2017. Today is 10/1/2017. Can the enrollee make a plan change?
- A.
• No, they are currently in a no change period.
- B.
• Yes, they qualify for a Good Cause plan change.
- C.
• No, they are a mandatory enrollee and must keep current plan.
- D.
• Yes, they are currently in their 120 day change period.
Correct Answer
D. • Yes, they are currently in their 120 day change period.Explanation
The enrollee can make a plan change because they are currently in their 120 day change period. This means that within 120 days of becoming eligible for Medicaid, they have the opportunity to switch plans if their PCP does not accept their current plan. Since the enrollee received Medicaid eligibility on 8/1/2017 and the plan became effective on 9/1/2017, they are still within the 120 day change period as today is 10/1/2017.Rate this question:
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- 2.
The recipient calls to enroll into a managed care plan. What are their enrollment options?
- A.
• Only FFS because they are voluntary.
- B.
• Cannot enroll into a plan because of an active TPL on file.
- C.
• The recipient is voluntary because of the TPL 14 on file and they have the options of either remaining on FFS or enrolling into a health plan.
- D.
• Only enroll into a plan and cannot have FFS because of the TPL on file.
Correct Answer
C. • The recipient is voluntary because of the TPL 14 on file and they have the options of either remaining on FFS or enrolling into a health plan.Explanation
The recipient is considered voluntary because of the TPL 14 on file. This means that they have the choice to either remain on FFS (Fee-for-Service) or enroll into a health plan. They are not limited to only one option and can choose whichever option suits them best. The TPL on file does not prevent them from enrolling into a health plan.Rate this question:
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- 3.
The recipient calls to enroll into a plan, but when reviewing the MMA hover you see there is an exemption on file. What is the best way to proceed?
- A.
• Inform the recipient they cannot enroll into a plan because they are exempt from being able to have any kind of Medicaid coverage.
- B.
• Inform the recipient they have APD and cannot enroll into a plan. Refer the recipient to DCF to have the demise date removed.
- C.
• Inform the recipient they are dually eligible due to the exemption and can only have FFS.
- D.
• Inform the recipient they cannot enroll into a plan because there is an exemption on the case.
Correct Answer
D. • Inform the recipient they cannot enroll into a plan because there is an exemption on the case.Explanation
The best way to proceed is to inform the recipient that they cannot enroll into a plan because there is an exemption on the case. This means that they are exempt from being able to have any kind of Medicaid coverage.Rate this question:
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- 4.
Why is the enrollee listed below Excluded from enrolling into a LTC plan?
- A.
• Enrollee is receiving Medicaid from the Social Security Administration.
- B.
• Enrollee has APD: IC meaning they are currently incarcerated.
- C.
• Medicaid ended on 9/1/2010.
- D.
• Enrollee is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities.
Correct Answer
D. • Enrollee is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities.Explanation
The enrollee is excluded from enrolling into a LTC plan because they are currently living in an Intermediate Care Facility for Persons with Developmental Disabilities. This indicates that they are already receiving care and support in a specialized facility, and therefore do not need additional coverage from a LTC plan.Rate this question:
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- 5.
Why is the enrollee below categorized as Voluntary?
- A.
• The enrollee has (LTCC) indicator next to his level of care.
- B.
• The enrollee has APD: WL meaning he is on the Agency for Persons with Disabilities Waitlist.
- C.
• The enrollee has (MWA) ACWM.
- D.
• The enrollee has APD: WL meaning he is on the Weight Loss Waiver Program.
Correct Answer
B. • The enrollee has APD: WL meaning he is on the Agency for Persons with Disabilities Waitlist.Explanation
The enrollee is categorized as Voluntary because he is on the Agency for Persons with Disabilities (APD) Waitlist. This indicates that he has voluntarily chosen to be on the waitlist for services provided by the APD. The other indicators such as LTCC, MWA, and APD: WL (Weight Loss Waiver Program) are not relevant to determining the enrollee's categorization as Voluntary.Rate this question:
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- 6.
What does a "T" shown for the enrollee's LTC eligibility category mean?
- A.
• The enrollee's LTC coverage has been terminated and they are no longer receiving services.
- B.
• The enrollee experienced a temporary loss and must pay for services until coverage is reinstated.
- C.
• The enrollee has experienced a temporary loss and will continue to receive services at no charge for 60 days.
- D.
• The enrollee is not eligible to be enrolled into a LTC plan.
Correct Answer
C. • The enrollee has experienced a temporary loss and will continue to receive services at no charge for 60 days.Explanation
The "T" shown for the enrollee's LTC eligibility category means that the enrollee has experienced a temporary loss and will continue to receive services at no charge for 60 days. This indicates that the enrollee's coverage has not been terminated but is temporarily suspended, and they will still receive the necessary services without any cost for a limited period of time.Rate this question:
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- 7.
This enrollee needs to update their address, where should they call?
- A.
• AHCA
- B.
• DOEA
- C.
• DCF
- D.
• SSA
Correct Answer
D. • SSAExplanation
Enrollees who need to update their address should call the Social Security Administration (SSA). The SSA is responsible for managing and maintaining individuals' Social Security records, including their address information. By calling the SSA, the enrollee can provide their updated address and ensure that their records are updated accordingly.Rate this question:
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- 8.
When reviewing a case, you see the recipient has an active QMB eligibility span and a TPL 11 on file. How would you describe this enrollee’s eligibility?
- A.
• The recipient will use FFS Medicaid to get services. Medicaid is primary and the private insurance is secondary.
- B.
• The Recipient has QMB, it is not full Medicaid coverage. It covers Medicare premiums, deductibles and coinsurance. The recipient also has a Medicare Special Needs plan (TPL 11) that will cover services.
- C.
• The recipient has Share of Cost. Medicaid will pay any service that is not covered by Medicare.
- D.
• The recipient has a Special Needs Plan that will cover 80% of services and QMB will cover the other 20% for doctor's visits and prescriptions.
Correct Answer
B. • The Recipient has QMB, it is not full Medicaid coverage. It covers Medicare premiums, deductibles and coinsurance. The recipient also has a Medicare Special Needs plan (TPL 11) that will cover services.Explanation
The recipient has QMB eligibility, which means they have coverage for Medicare premiums, deductibles, and coinsurance. However, this is not full Medicaid coverage. Additionally, the recipient has a Medicare Special Needs plan (TPL 11) that will cover services. This means that Medicaid is primary and the private insurance is secondary, with the recipient using FFS Medicaid to receive services.Rate this question:
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- 9.
The caller needs to know what plan their child has, and when reviewing the case you see a “K” for the eligibility category and the child is enrolled in Sunshine Health. How do you proceed?
- A.
• Refer to Sunshine Health
- B.
• Refer to DCF
- C.
• Refer to the MediKids Helpline
- D.
• Refer to AHCA
Correct Answer
C. • Refer to the MediKids HelplineExplanation
Based on the given information, the caller needs to know what plan their child has and the child is enrolled in Sunshine Health. However, the eligibility category is mentioned as "K". To proceed, it would be appropriate to refer the caller to the MediKids Helpline. This helpline can provide more specific information regarding the child's plan and eligibility category.Rate this question:
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- 10.
Mary does not want to be enrolled in a managed care plan anymore. She prefers to receive services using straight Medicaid because they have better doctors and she does not have to get referrals to see her specialist. How do you proceed?
- A.
• Submit a MC Exemption request to AHCA without supervisor approval because the enrollee wants straight Medicaid for a good reason.
- B.
• File a complaint against AHCA. Florida statute states enrollees have the right to choose a managed care plan or straight Medicaid.
- C.
• Submit a Supervisor Task for SNU because the caller needs to see her specialists.
- D.
• Explain to the caller that she must be enrolled in a managed care plan in order to receive services. Refer to DCF/SSA for eligibility redetermination. Exemption requests should only be filed with supervisor approval.
Correct Answer
D. • Explain to the caller that she must be enrolled in a managed care plan in order to receive services. Refer to DCF/SSA for eligibility redetermination. Exemption requests should only be filed with supervisor approval.Explanation
The correct answer is to explain to the caller that she must be enrolled in a managed care plan in order to receive services. This is because the caller prefers to receive services using straight Medicaid, but it is necessary for her to be enrolled in a managed care plan. The answer also suggests referring the caller to DCF/SSA for eligibility redetermination and states that exemption requests should only be filed with supervisor approval.Rate this question:
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- 11.
What should you do if the HIV/AIDS special condition is not listed in the system?
- A.
• Tell the caller their doctor must update their medical record and report it to AHCA.
- B.
• Tell the caller to fax us documentation of the special condition, so the case can be updated.
- C.
• Tell the caller they must report their special condition to the Centers for Disease Control and the Department of Health.
- D.
• Tell the caller the SNU Nurse will call them to get more information on their special condition and set up a home visit.
Correct Answer
B. • Tell the caller to fax us documentation of the special condition, so the case can be updated.Explanation
If the HIV/AIDS special condition is not listed in the system, the appropriate action would be to tell the caller to fax documentation of the special condition. This is necessary in order to update the case and ensure that the proper information is recorded.Rate this question:
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- 12.
An enrollee wants to know what kind of coverage they have. When reviewing the case you see the enrollee has a PACE Level of Care and is enrolled in a PACE plan. What can you inform the enrollee of their coverage?
- A.
• The enrollee is enrolled in PACE and will receive medical and Long-Term Care services from PACE.
- B.
• The enrollee has a private insurance on file and will receive all services through the private insurance.
- C.
• The enrollee receives LTC services through the PACE plan because they are disabled, so they can use FFS for their medical coverage.
- D.
• All PACE enrollees qualify to receive extra benefits through LTC plans.
Correct Answer
A. • The enrollee is enrolled in PACE and will receive medical and Long-Term Care services from PACE.Explanation
The enrollee has a PACE Level of Care and is enrolled in a PACE plan, which means they will receive medical and Long-Term Care services from PACE. This indicates that their coverage is provided by PACE and they can expect to receive the necessary healthcare services from this plan.Rate this question:
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- 13.
Which of the following is Voluntary for an MMA enrollment?
- A.
• Recipients that receive Supplemental Security Income
- B.
• Recipients with APD
- C.
Recipients with Medicare
- D.
• Recipients that are in foster care
Correct Answer
B. • Recipients with APDExplanation
Recipients with APD refers to individuals who have been diagnosed with an Acquired Perceptual Deficit. This condition affects their ability to process sensory information, which can impact their daily functioning. Enrollment in an MMA (Medicare Modernization Act) program is voluntary for individuals with APD, meaning they have the choice to enroll or not.Rate this question:
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- 14.
If the enrollee has an active CMS span on file...
- A.
• then the CMS questions will not have to be asked.
- B.
• then they will have to contact CMS directly to enroll.
- C.
• then the CMS questions have to be asked.
- D.
• then they cannot enroll into CMS.
Correct Answer
A. • then the CMS questions will not have to be asked.Explanation
If the enrollee has an active CMS span on file, it means that their information and enrollment status with CMS (Centers for Medicare and Medicaid Services) is already known and up to date. Therefore, there is no need to ask the CMS questions again as the information is already available.Rate this question:
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- 15.
If the CMS special condition expires...
- A.
• then the child will have 60 days to continue to receive 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.Rate this question:
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- 16.
If a newly eligible child has an active CMS and HOMESAFENET span, which specialty plan will the enrollee 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 WelfareExplanation
If a newly eligible child has an active CMS and HOMESAFENET span, they will be auto-assigned to the Sunshine Health Child Welfare specialty plan based on the specialty plan hierarchy.Rate this question:
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- 17.
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, so she wants to know what kind of coverage she has. You look in HealthTrack and see Flora has a QI1 active span. What can you inform Flora about her coverage?
- A.
• Tell Flora, she can't choose a plan and discontinue the call.
- B.
• Advise Flora that Medicare is her primary insurance and she has limited Medicaid coverage that covers Medicare part B premiums.
- 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 covers Medicare part B premiums.Explanation
Flora has a QI1 active span, which means that she has limited Medicaid coverage that covers Medicare part B premiums. Therefore, she cannot choose a plan, but she can be informed that Medicare is her primary insurance and she has coverage for Medicare part B premiums through Medicaid.Rate this question:
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- 18.
If a newly eligible member has an active SMI and HIV Span, which specialty plan will the enrollee 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
D. Positive Healthcare/Clear Health AllianceExplanation
If a newly eligible member has an active SMI and HIV Span, they will be auto-assigned to the Positive Healthcare/Clear Health Alliance specialty plan based on the specialty plan hierarchy.Rate this question:
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- 19.
When a recipient has an "A" or "N" in HT for MMA, you should...
- A.
• Refer the caller to DCF/SSA because they are not eligible yet.
- B.
• Do not ask questions and automatically transfer to Express Enrollment.
- C.
• Follow the script to determine if the recipient needs to be transferred to Express Enrollment.
- D.
• Advise the recipient to allow 24-48 business hours for their eligibility to update and call back.
Correct Answer
C. • Follow the script to determine if the recipient needs to be transferred to Express Enrollment.Explanation
If a recipient has an "A" or "N" in HT for MMA, the correct action is to follow the script to determine if the recipient needs to be transferred to Express Enrollment. This means that the recipient's eligibility for Express Enrollment will be assessed based on the information provided in the script, and a decision will be made accordingly. The other options, such as referring the caller to DCF/SSA or automatically transferring to Express Enrollment without asking questions, are not appropriate in this situation. Advising the recipient to allow 24-48 business hours for their eligibility to update and call back is also not the correct action to take.Rate this question:
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- 20.
An enrollee wants to know if they can change their plan. When reviewing the case you see they are Medicaid Pending and enrolled in Sunshine Health. What options are available to this recipient?
- A.
• The enrollee can change to any other available LTC plan.
- B.
• Inform the recipient they are not eligible to make a plan change because they are in their Lock-in period.
- C.
• The enrollee can remain in Sunshine Health or disenroll from the LTC program to stop services until Medicaid is approved.
- D.
• Refer the recipient to DOEA to get an exemption because LTC recipients do not make plan changes without exemptions.
Correct Answer
C. • The enrollee can remain in Sunshine Health or disenroll from the LTC program to stop services until Medicaid is approved.Explanation
The enrollee, who is Medicaid Pending and enrolled in Sunshine Health, has the option to either remain in Sunshine Health or disenroll from the LTC program until Medicaid is approved. This means that they can continue receiving services from Sunshine Health or temporarily stop receiving services until their Medicaid application is approved.Rate this question:
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Mar 21, 2023Quiz Edited by
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Sep 21, 2017Quiz Created by
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