Smmc: Written Assessment

The correct answer is "No, the recipient does not meet the age restrictions of the provider." This means that the recipient cannot be enrolled with the PCP mentioned because they do not meet the age requirements set by the provider.

The member is excluded from enrolling into a LTC plan because he is currently living in an Intermediate Care Facility for Persons with Developmental Disabilities. This type of facility provides specialized care for individuals with developmental disabilities, and it is likely that the facility already provides the necessary long-term care services that would be covered by a LTC plan. Therefore, enrolling in a separate LTC plan would be redundant in this case.

The member below is categorized as Voluntary under LTC because she has APD: WL, which stands for Agency for Persons with Disabilities Waitlist. This indicates that she is on the waitlist for the Agency for Persons with Disabilities, suggesting that she voluntarily sought out their services. The other indicators, such as LTCC, MWA, and ACWM, do not directly relate to her categorization as Voluntary under LTC.

The 'R' in this context refers to the member being able to be enrolled in the same plan they had previously, if they gain full eligibility within 6 months. This means that if the member's eligibility status changes and they become fully eligible for Medicaid within 6 months, they have the opportunity to continue receiving services under the same plan they were enrolled in before, if that plan is still available.

The correct answer is to 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. This means that Flora cannot choose a separate plan for Medicaid coverage, but Medicaid will help cover some of the costs that Medicare does not.

During a "temporary loss" period in the LTC program, enrollees will continue to receive services from the LTC plan for a maximum of 60 days. However, they will not be able to change to a different LTC plan during this period.

An OB/GYN doctor can be a PCP as long as they are listed as a Primary Care Provider. This means that they are recognized and authorized to provide primary care services to patients. Being a specialist in obstetrics and gynecology does not exclude them from also serving as a PCP, as long as they have the necessary qualifications and are listed as such.

The QMB Program allows qualified individuals to have Medicaid cover their Medicare premiums, deductibles, and coinsurance. This means that eligible individuals can receive financial assistance from Medicaid to help with the costs associated with their Medicare coverage.

The correct answer is "LTC or Comprehensive enrollments." This means that the special conditions "LTC Non-COMP" and "SMMC COMP Enrolled" are added to a member's profile if they have either a long-term care (LTC) enrollment or a comprehensive enrollment. This suggests that these special conditions are specifically related to the type of enrollment the member has, whether it is for long-term care or comprehensive coverage.

The SLMB Program allows qualified individuals to have Medicaid pay Medicare for Medicare Part B premiums. This means that individuals who meet the eligibility criteria can have their Medicare Part B premiums covered by Medicaid, reducing their out-of-pocket expenses. This program is beneficial for those who may struggle to afford the monthly premiums on their own.

The correct answer is to ask Rosa whether she has authority to obtain information or make changes for the person she is calling for and continue with normal verification procedure. This is the appropriate response because it allows Rosa the opportunity to confirm her authorization to make changes for her daughter, Ashley. By proceeding with the normal verification procedure, the representative can ensure that the person on the call has the necessary authority to make changes or obtain information.

If a recipient is enrolled in Medicaid Pending, they are not able to switch to a different managed care plan. However, they do have the option to disenroll from the current plan, which will result in discontinuation of services. This means that if the recipient is not eligible for Medicaid, they will not be responsible for any services rendered and the managed care plan may terminate services and seek reimbursement. Additionally, recipients who are in a nursing facility can still enroll under Medicaid Pending. The recipient will have a 60-day period to obtain Medicaid eligibility.

Based on the given information, the recipient would be excluded for MMA enrollment.

The fact that Roger is listed in the physical address field with C/O (in care of) for his mother does not automatically authorize him. He still needs to pass verification to determine if he is authorized on the case.

The correct answer is when the recipient can choose to enroll and not start services until Medicaid has been approved. This means that the recipient has the option to sign up for the LTC program but can delay starting the services until their Medicaid eligibility has been confirmed.

The correct answer is to advise Paul that the MMA plan is responsible for coordinating his care with Medicare and ensuring that the MMA plan does not authorize or provide duplicative services. This is the appropriate course of action because MMA plans are designed to work in conjunction with Medicare, and the MMA plan's case manager can provide further assistance and guidance in determining coverage for Paul's services.

The CARES assessment is designed to identify the long-term care needs of individuals and recommend the most suitable placement for them. It aims to find the least restrictive and safest environment for the person while ensuring that their care needs are met appropriately. Additionally, the assessment helps establish the appropriate Level of Care required for the individual.

The correct answer is to refer Susan to Medicare to find out which MMA plan is affiliated with her Medicare plan. This is the best course of action because Medicare would have the most accurate and up-to-date information regarding the affiliation between Medicare and MMA plans. Medicare would be able to provide Susan with the specific details she needs to determine which MMA plan is affiliated with her Medicare plan.

The correct answer is "the plan" because the question is asking who the recipient should call for details about benefits or prior authorizations that are not listed on the plan brochure. It can be inferred that the plan referred to here is the healthcare plan or insurance plan that the recipient is enrolled in. Therefore, calling the plan directly would be the appropriate course of action to obtain the necessary information.

The Care Coordinator/Case manager is responsible for developing a plan of care, assisting the enrollee in obtaining appropriate care, and meeting with the enrollee to perform an assessment. However, they do not have the authority to become the Power of Attorney and make changes to the recipient's case. This role is typically fulfilled by a legal representative or family member appointed as the Power of Attorney.

Medicaid Pending enrollments are available to HCBS individuals. HCBS stands for Home and Community Based Services, which are designed to provide long-term care services and support to individuals who prefer to receive assistance in their own homes or community settings rather than in institutions. This answer suggests that individuals who qualify for HCBS services can enroll in Medicaid while their application is still pending, allowing them to access the necessary care and support during the waiting period.

MMA plans must provide continuity of care for up to 60 days. This means that individuals who are enrolled in an MMA plan will have access to consistent and uninterrupted healthcare services for a period of 60 days. This ensures that individuals can receive the necessary medical treatments and services without any gaps or disruptions in their care. It is important for MMA plans to offer this continuity of care to promote the health and well-being of their members.

Continuity of Care is a concept that ensures patients can continue receiving care from their current healthcare provider even if there are changes in their insurance plan. In this case, the caller has been seeing a specialist who accepted their old plan and now they have switched to a new plan. Since the caller has been in the new plan for less than 60 days and it takes a long time to get an appointment with this specialist, it is important to explain Continuity of Care to the caller. This will help them understand that they may still be able to see the specialist and provide them with information on how to proceed with their current plan.

The correct answer is that the 120 days will start on the first day of the month that eligibility is received. This means that once a person becomes eligible for Med Pending enrollments, they will have 120 days from the beginning of the next month to try out the plan.

Recipients who no longer need Long-Term Care (LTC) services can disenroll to terminate their LTC services. This means that if a recipient's condition improves or they no longer require the level of care provided by LTC services, they have the option to disenroll and end their participation in the program. This allows resources to be allocated to individuals who are in greater need of LTC services.

If the caller states that the LTC plans are not providing them information about benefits, limits, service providers, extra services, cost sharing, etc., the appropriate action to take is to file a complaint. This is because the caller is not receiving the necessary information about their LTC plans, which is a violation of their rights. By filing a complaint, the issue can be addressed and resolved, ensuring that the caller receives the required information about their LTC plans.

Recipients with HOMESAFENET as an active special condition are eligible to enroll into the Sunshine Health Child Welfare Plan. This plan specifically caters to the needs of children in the child welfare system, ensuring they receive comprehensive healthcare services. Therefore, it is the appropriate specialty plan for recipients with HOMESAFENET as an active special condition.

The correct answer states that the member is enrolled in United, she has the option to disenroll and use Fee-for-Service (FFS), she was pregnant, and she was linked to her baby. This means that the member is currently enrolled in a United plan, but she has the choice to disenroll and use FFS instead. Additionally, she was pregnant and was linked to her baby, indicating that there is a connection or association between the member and her baby.

The member needs to update her address, so the appropriate place to refer her would be the Social Security Administration (SSA). The SSA is responsible for maintaining records and information related to Social Security benefits, including personal information such as addresses. Therefore, they would be the most suitable entity to handle address updates for the member.

The correct answer is "Member was auto assigned by Health Track." This means that the member did not voluntarily enroll themselves into the health plan. Instead, Health Track automatically assigned them to the plan, possibly based on certain criteria or eligibility requirements.

To complete a plan change from PACE into a LTC plan, the recipient must call the Elder Helpline. This suggests that the Elder Helpline is the appropriate channel to request a plan change in this specific scenario. It is likely that the Elder Helpline has the necessary resources and information to guide the recipient through the process of changing their plan. Calling SSA or the SMMC line may not be the correct option as they may not be directly involved in facilitating plan changes. Completing the plan change online is not mentioned as a requirement, indicating that calling the Elder Helpline is the preferred method.

The correct answer is "No, the agent may skip the authorization question if they are calling for themselves." This is because if someone is calling for themselves, they already have the authority and permission to obtain information or make changes for themselves. Therefore, it is not necessary for the agent to ask them if they have authority or permission.

The recipient is referring to Homemaker Services. This is evident from the statement that Sue helps with cooking and helping around the house, which are tasks typically covered under Homemaker Services.

The "T" shown for the recipient's LTC coverage means that the recipient has experienced a temporary loss and will continue to receive services at no charge for 60 days. This indicates that there may have been a disruption in the recipient's coverage, but they will still be able to receive services without having to pay for them for a certain period of time.

The correct answer is to document the caller's Name, Agency & Title, Work Phone Number, Statement of Authority and continue with the call. This is the appropriate response because it allows for proper identification and verification of the caller's credentials. By documenting this information, it ensures that the worker can confirm the legitimacy of the caller and proceed with the call in a professional manner.

Continuity of Care applies when a recipient changes from one plan to another plan. This means that when a recipient switches from one healthcare plan to another, they are entitled to continue receiving the same level of care and services without interruption. This ensures that the recipient's healthcare needs are met and that there is a smooth transition between plans.

The correct answer is Billing and Payment. This is because Rita Bailey is complaining about being required to pay for services that her plan is supposed to cover. This falls under the category of Billing and Payment as it involves issues related to the payment process and coverage of services.

In this scenario, Anita Stephens has called to complain about the behavior of an AHS Choice Counseling Specialist. The appropriate course of action would be to process the complaint request through HeathTrack, which is a system used for handling complaints. By doing so, Anita's complaint will be officially recorded and she will be provided with a complaint number for reference. This allows for proper documentation and tracking of the complaint.

The correct answer is High: describes dissatisfaction with a medical issue that may be detrimental to the recipient's health. This is because Anthony Wolf is complaining about AHCA refusing to pay for his bariatric surgery, which he depends on for survival. This dissatisfaction with the denial of a necessary medical procedure can potentially have a negative impact on the recipient's health.

The correct answer is to select MC EX/SC in Health Track, click on the special condition box, and submit the request. This option is the most appropriate because it directly addresses the issue of removing special conditions from a recipient's case. By selecting MC EX/SC in Health Track and submitting the request, the agent can initiate the necessary steps to remove the special condition. The other options mentioned in the question do not specifically address the removal of special conditions or may not be the most effective course of action in this situation.

The correct answer is that the counselor should notify Sirena that legal documentation of her emancipation must be faxed in before she can speak for herself; she can continue the call on the newborn's behalf. This is because even though Sirena claims to be emancipated, the counselor needs proof of this emancipation before allowing her to speak on her own behalf.

The correct answer is to advise the caller they are required to be in a plan to continue receiving services and ask what is their reason for wanting FFS/Straight Medicaid. This is the appropriate response because it addresses the caller's request while also informing them of the requirement to be in a plan. By asking for their reason, the agent can gather more information and potentially address any concerns or misconceptions the caller may have. It allows for a conversation to take place and for the agent to provide the necessary information and guidance.

The correct answer is to not complete verification and refer the caller to the MediKids Helpline. This suggests that completing verification may not be necessary or appropriate in this case, and instead the caller should be directed to the helpline for further assistance.

If the HIV/AIDS special condition is not listed in the system, the caller should be instructed to fax documentation of the special condition. This is necessary in order to update the case with the relevant information.

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.

If a newly eligible child has an active CMS and HOMESAFENET span, the member will be auto-assigned to the Sunshine Health Child Welfare specialty plan based on the specialty plan hierarchy.

The correct answer is that the member cannot enroll in LTC because she does not have a level of care. This means that she does not meet the criteria or requirements for receiving long-term care services. It is not mentioned in the given information that the member is pregnant or that she has a Medicaid application. Therefore, these factors are not relevant to the explanation.

The correct answer is "The member completed an express enrollment." This means that the member enrolled by completing an express enrollment process. This could involve filling out an online form or providing necessary information over the phone to quickly enroll in the program or service.

The correct answer is to explain Continuity of Care and refer to the new plan for more information. This option acknowledges the caller's concern about their appointment with their old doctor and provides a solution by explaining the concept of Continuity of Care. By referring the caller to the new plan for more information, they can get specific details about how to proceed with their appointment and any potential coverage or reimbursement options.

The correct answer is to explain continuity of care and tell the caller to call the new plan and provide them with prescription information. This is the best course of action because it addresses the caller's concern about not being able to afford their medication and provides a potential solution by contacting the new plan. Explaining continuity of care also helps the caller understand the importance of maintaining their medication regimen and seeking assistance from their new plan.