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*
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*
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)