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Navigator Reporting Form 2020 – 2021
Home
Navigator Reporting Form 2020 – 2021
Navigator Reporting Form 2020 - 2021
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
*
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
Catherine Center
Washtenaw Health Plan
Friends of Parkside
Community Health Access Coalition
Community Welfare Services of Metro Detroit
American Chinese Association
Traverse Health Clinic
Northern Michigan Health services
Hamilton Community Health Network
Refugee Development Center
Intercare Community Health Network
Center for Family Health
Alcona Health Center
Isabella Citizens for Health
Ruth Ellis Center
Family Health Care
211 Northeast Michigan
MPCA
Thunder Bay Community Health Service
Centro Multicultural La Familia
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).
Addressing general inquiries about health insurance options
*
How many people request general inquires
Understanding basic concepts and rights related to health coverage and how to use it:
*
Select All
Health insurance literacy
Locating providers
Billing and payment questions
Accessing preventative health services
Evaluating health care options using tools and information available through a consumer's health plan
Marketplace Application Assessment and Preparation
*
Healthcare.gov Account Creation or Troubleshooting
Marketplace Eligibility Assessment and Results Review
Marketplace Plan Compare
N/A
Marketplace Application Submission and Enrollment (Re-enrollment)
*
Electronic QHP Enrollment using Healthcare.gov
Telephonic QHP Enrollment using Marketplace Call Center
Written QHP Enrollment using a paper Marketplace Application
N/A
Complex Cases and Other Marketplace Enrollment Issues
*
Complex Case Help Center Assistance and Referrals
Data matching issues/Periodic data matching issues assistance
SEP eligibility troubleshooting assistance
Employer-sponsored coverage issues assistance
APTC/CSR assistance
N/A
Answering questions about and/or making referrals to:
*
Agent/broker
Issuer
Medicare
Other consumer assistance/health insurance program
State departments of insurance/Medicaid
N/A
Forms, Exemptions and Appeals:
*
Marketplace tax forms (1095-A)
Assisted with Taxes ( 1095-B)
Filing Marketplace exemptions
Submitting Marketplace or insurance coverage appeals
N/A
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
Uploading Documents
These tend to be general inquiries
Medicaid Application Enrollment/Assessment and preparation
*
Healthy Michigan Plan (expanded Medicaid)
Electronic application using MIBridges.gov
Written Application using Medicaid Form
N/A
Type of Enrollment Assistance Provided
*
Provided Education Only (no enrollment was completed)
Completed Partial Enrollment
Completed/Redetermination form/Medicaid
Selected a Health Insurance Plan through the Marketplace
Selected a Health Insurance Plan through Medicaid
Referred Client
Special Enrollment Period Assistance/Verification/Enrollment
SEP eligibility troubleshooting assistance
Please select one of the following
Nature of Service Provided During Session
*
Q&A Information Session
Created Online Account/Medicaid
Completed Eligibility Application
Selecting/Enrolling in a Plan
Reporting a Life Change
Assisted with filing a Medicaid Exemption
Referred to Medicaid (sent to DHS office)
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
Did not assist with Post Enrollment
N/A
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
N/A
What county does the client live in?
*
Wayne
Oakland
Macomb
Did you provide the client with tobacco cessation resources?
*
Yes
No
N/A
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)
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