Certified Application Counselor (CAC) Program Designated Organization Application

Size: px

Start display at page:

Download "Certified Application Counselor (CAC) Program Designated Organization Application"

Stuart Cannon
5 years ago
Views:

2014-15 Certified Application Counselor (CAC) Program Designated Organization Application Instructions: Organizations interested in being designated as Designated Organizations must complete and

Please include your organization name in the title of each document. The attachments will automatically be uploaded into our file management system.

1 Certified Application Counselor (CAC) Program Designated Organization Application Instructions: Organizations interested in being designated as Designated Organizations must complete and upload via the following application, all attachments and the signed CAC Designated Organization Agreement to Please include your organization name in the title of each document. The attachments will automatically be uploaded into our file management system. Once submitted, you will receive a confirmation . For more information on the CAC Program and criteria, please visit Organization Information Organization Name: Mailing Address: Administrative Physical Address: Type of Organization (Government Agency/Health Services Provider/Social Services Organization/Other please specify): Is your organization currently a MA/PE/CAAS Site for Colorado Health Care Policy and Financing? Yes No Is your organization a Federally Qualified Health Center receiving HRSA funding for outreach and enrollment? Yes No Primary Application Contact Information This is the contact person for the submission of this application. Last Name: First Name: Position Title: Address: Phone Number: NOTE IF YOUR ORGANIZATION WILL BE STAFFING CACS AT MULTIPLE FACILITIES, PLEASE USE ATTACHMENT A TO PROVIDE INFORMATION ON EACH FACILITY.

2 Primary Program Contact Information This is the contact person for ongoing program management, who will be responsible for overseeing administration of the CAC Program and will receive s and other contact from Connect for Health Colorado. Last Name: First Name: Position Title: Address: Phone Number: Organization Qualifications Does your organization currently help individuals or families with financial assistance, application assistance, or enrollment into financial or health programs? Yes No Does your organization have policies and procedures in place to protect the privacy of customer information? Yes No If yes, please provide a copy of your policies/procedures on this as an attachment to this application. Does your organization have policies and procedures in place for staff and volunteer background checks? Yes No If yes, please provide a copy of your policies/procedures on this as an attachment to this application. Does your organization have a non-discrimination and inclusion policy? Yes No Does your organization have ADA accessibility and have policies and practices in place to provide reasonable accommodations? Yes No Will your organization agree to refer customers with unmet language interpretation or translation needs to Connect for Health Colorado customer service network? Yes No Does your organization have policies and procedures in place for assessing and evaluating customer service quality and escalating customer complaints for resolution? Yes No If yes, please provide a copy of your policies/procedures on this as an attachment to this application. Does your organization have liability, Employee Crime and Dishonesty insurance and Privacy insurance in the coverage amounts required? Yes No If yes, please provide a copy of your insurance certificates as an attachment to this application. Does your organization agree to provide reporting to Connect for Health Colorado and undergo audit of practices on the request of Connect for Health Colorado? Yes No

3 Organization Disclosures Designated organizations are required to disclose conflicts of interest to Connect for Health Colorado and to customers. Is your organization a health insurance issuer, issuer of stop loss insurance, a subsidiary of a health insurance issuer or issuer of stop loss, or an organization that lobbies on behalf of the industry? Yes No Does your organization receive compensation directly or indirectly from health insurance issuers or issuers of stop loss insurance? Yes No If yes, describe:. Disclose any funding your agency receives to provide consumer assistance to individuals or households applying/enrolling in health insurance. NOTE UNDER RECENT CHANGES TO FEDERAL REGULATION 45 CFR , CACS WILL NO LONGER BE ALLOWED TO RECEIVE CONSIDERATION, DIRECTLY OR INDIRECTLY, FROM HEALTH INSURANCE ISSUERS OR STOP LOSS ISSUERS IN CONNECTION WITH THE ENROLLMENT OF CONSUMERS IN QUALIFIED HEALTH PLANS (QHPS) OR NON-QHPS. Organization Operations Please describe, in detail, how your CACs provide application assistance to customers including: screening the customer for potential benefits eligibility, process for walking the customer through the eligibility determination and plan enrollment, and any successes/challenges in getting the customer enrolled. _

4 Designated Organizations are responsible for certifying and monitoring the performance of their staff in accordance with Federal Regulation 45 CFR Please describe, in detail, how you will meet the following requirements: 1. CACs must complete Marketplace approved training regarding qualified health plan (QHP) options, insurance affordability programs, eligibility, and benefits rules and regulations governing all insurance affordability programs operated in Colorado, as implemented in Colorado, and completes and achieves a passing score on all Marketplace approved certification examinations, prior to functioning as a CAC. 2. CACs disclose to the designated organization and potential customers any relationships the CAC or designated organization has with QHPs or insurance affordability programs or other potential conflicts of interest. 3. CACs comply with the Marketplace s privacy and security standards adopted consistent with , and applicable authentication and data security standards. 4. CACs agree to act in the best interest of the customers assisted. 5. Either directly or through an appropriate referral to a Certified Health Coverage Guide (HCG), non-hcg assistance personnel or the Marketplace Customer Service Center, provides information in a manner that is accessible to individuals with disabilities, as defined by the Americans with Disabilities Act (ADA), as amended. 6. Customers are informed of the functions and responsibilities of CACs.

5 7. Customers provide authorization prior to CACs obtaining access to a customer s personally identifiable information and that the designated organization or CAC maintains a record of the authorization provided. 8. Customer may revoke at any time the authorization provided to the CAC. 9. Designated organizations and CACs may not impose any charge on customers for applications or other assistance related to the Marketplace. I affirm that I am authorized to submit this application on behalf of the applicant organization and that all of the information contained herein is true and correct. Signature: Date: Printed Name/Title **Required Attachments** A Multiple Facility Information (if applicable) B Copy of organization s Liability, Employee Crime and Dishonesty insurance and Privacy insurance certificate(s) C Copies of the following organizational policies and procedures on: customer privacy and security staff and volunteer background checks assessing and evaluating customer service quality and escalating customer complaints for resolution Instructions: Organizations interested in being re-designated as Designated Organizations must complete and upload via the following application, all attachments and the signed CAC

6 Designated Organization Agreement to Please include your organization name in the title of each document. The attachments will automatically be uploaded into our file management system. Once submitted, you will receive a confirmation .

7 Attachment A Multiple Facility Information CAC Program - Designated Organization Re-designation Application Organization Name: Facility Name: Number of CACs: Mailing Address: Administrative Physical Address: Primary Contact Last Name: First Name: Position Title: Address: Phone Number: Facility Name: Number of CACs: Mailing Address: Administrative Physical Address: Primary Contact Last Name: First Name: Position Title: Address: Phone Number: Facility Name: Number of CACs: Mailing Address: Administrative Physical Address: Primary Contact Last Name: First Name: Position Title: Address: Phone Number:

Adopted Permanent Rules Relating to Policies and Procedures to Certify Entities to Deliver Consumer Assistance Services

1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 Adopted Permanent Rules Relating to Policies and Procedures to Certify Entities to Deliver