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Navigator Reporting Form 2019-2020
Home
Navigator Reporting Form 2019-2020
Navigator Reporting Form 2019-2020
This is the navigator reporting form
Navigator ID
*
This is your Navigator ID number (ex. MINAVC40000XX)
Email
*
Length of Service
*
5
10
15
20
30
45
60
90
120
Please specify in minutes the length of time you spent with the client
Date of Service
*
Date Format: MM slash DD slash YYYY
Enrollment Location
*
ACCESS Maple
ACCESS Schaefer
ACCESS Saulino Court
ACCESS Ferndale
ACCESS Sterling Heights
ACCESS Detroit
JFS West Bloomfield
JFS Oak Park
Ferncare Clinic
Phone Call/Not Applicable
Other
If other please list:
Client Identifier
*
Must be healthcare.gov identifier or first name if not applicable
Enrollment Size
*
How many people will be enrolling? (ex. 1, 4, 6, etc).
You helped the client with:
*
A new qualified health plan/account
Renewing a policy from before
General Telephone Call
General Email Inquiry
General/Basic Conversation
Coverage to Care/Health Insurance Literacy
These tend to be general inquiries
Type of Application Filed
*
Health Insurance Marketplace (healthcare.gov)
Healthy Michigan Plan (expanded Medicaid)
N/A
Type of Enrollment Assistance Provided
*
Provided Education Only (no enrollment was completed)
Applied for Medicaid/CHIP
Completed Partial Enrollment
Selected a Health Insurance Plan through the Marketplace
Selected a Health Insurance Plan through Medicaid
Referred Client
Special Enrollment Period Assistance/Verification/Enrollment
Please select one of the following
Nature of Service Provided During Session
Q&A Information Session
Created Online Account
Completed Eligibility Application
Comparing Plans
Selecting/Enrolling in a Plan
Reporting a Life Change
Billing and Payment
Locating Providers
Assisted with Taxes (Marketplace 1095-A)
Assisted with Taxes (Medicaid 1095-B)
Assisted with filing a Marketplace Exemption
Assisted with filing a Medicaid Exemption
Data Matching Issues/Periodic Data Matching Issues
Issue/Problem with Employer-sponsored Coverage
Issue/Problem with Advance Premium Tax Credit (APTC)/Cost Sharing Reduction (CSR)
Referred to Medicaid (sent to DHS office)
Referred to Medicare
Referred to other Consumer Assistance/Health Insurance Program
Referred to Issuers (Health Insurance Company)
Referred to Agent/Broker for SHOP
Referred to State Departments of Insurance (Veterans)
Provided Advocacy Resources
Please select all services provided during the appointment
Did the client receive a tax credit?
*
Yes
No
N/A
Did the client receive cost sharing?
*
Yes
No
N/A
Assisting Consumers with Post Enrollment Assistance
*
Assisted with an Appeal
Filed a grievance about an insurance company
Helped with Change in Circumstance
Health Insurance Literacy (Coverage to Care)
Did not assist with Post Enrollment
How many times has this client come to the office this year?
*
1st Visit
2nd Visit
3rd Visit
4th or more visits
Is this a repeat client?
Plan Level
*
Bronze
Silver
Gold
Catastrophic
Medicaid
N/A
Ethnicity/Race
*
Arab
White
South Asian (Indian, Pakistani, Bangladeshi)
Asian
African American
Native American/Alaska Native
Hispanic/Latino
Native Hawaiian/Pacific Islander
Language Used during service
*
Arabic
English
Spanish
Russian
Bengali
Hindi/Urdu
Gujarati
Chaldean
Client Age
*
Under 20
20-29
30-39
40-49
50-59
60-79
Over 80
Estimated age of client enrolling in health plan
Gender
*
Male
Female
Citizenship Status
*
US Citizen
Green Card Holder/Immigrant
Refugee/Asylee
Work Authorization Visa
Employment Status
*
Employed
Unemployed
Not in Labor Force
Estimated Client Income
*
Less than $10,000
$10,000-$19,000
$20,000-$49,000
Over $50,000
What county does the client live in?
*
Wayne
Oakland
Macomb
Did you provide the client with tobacco cessation resources?
*
Yes
No
Did you have a conversation and/or provide tobacco cessation resources during the enrollment process?
Did your client fill out a coverage to care form?
*
Yes
No
Did you discuss COVID-19 with your client?
*
Yes
No
This includes testing and locations
Session Outcome
*
Detailed notes of session and final outcomes
If applicable, who referred this client to us?
How did the client end up at ACCESS (who sent them, where did they see the flyer, etc)