• Under a Cooperative Agreement from the Centers for Medicare and Medicaid Services (CMS) to Support Navigators in Federally-facilitated Exchanges (FFEs), ACCESS serves as the Prime Grantee to the following Subcontractors:
  • To be sure you are making an informed decision to provide your personal information to ACCESS AND ITS SUBCONTRACTORS to help you with understanding your health coverage options and completing an application for health coverage through the Marketplace, ACCESS AND ITS SUBCONTRACTORS should talk with you about the following things before asking you to sign the Consent Form giving your permission for help. ACCESS AND ITS SUBCONTRACTORS will help me, to the best of their ability, as I learn about my health coverage options. ACCESS AND ITS SUBCONTRACTORS will not choose a health plan for me. ACCESS AND ITS SUBCONTRACTORS will keep my personal information private and secure. ACCESS AND ITS SUBCONTRACTORS should not store my personal information except for limited reasons, such as taking my name and phone number when arranging for an appointment for me to meet with a Navigator or keeping a copy of my Consent Form. ACCESS AND ITS SUBCONTRACTORS will make sure that any stored information is kept private and secure. ACCESS AND ITS SUBCONTRACTORS will need to see and use my personal information in order to do their job as a Navigator and help me in applying for health coverage. ACCESS AND ITS SUBCONTRACTORS should not keep anything with my personal information included on it after our meeting is over, other than a copy of my Consent Form. ACCESS AND ITS SUBCONTRACTORS is required to have knowledge about health insurance available in the Marketplace, as well as other health coverage like Medicaid and CHIP. I understand that nothing requires me to share information with ACCESS AND ITS SUBCONTRACTOR. ACCESS AND ITS SUBCONTRACTORS will help me based on the information that I provide. ACCESS AND ITS SUBCONTRACTORS will help me understand my health insurance options in the language I speak/understand or will refer me to other assistance that is able to provide information in the language I speak/understand. ACCESS AND ITS SUBCONTRACTORS should not charge me any money for helping me. ACCESS AND ITS SUBCONTRACTORS will provide me with a copy of my Consent Form and this Cover Sheet, once complete. I can cancel my consent at any time. In this consent form: Subcontractor means an organization that receives Federal funding through ACCESS’ Cooperative Agreement with the Centers for Medicare and Medicaid Services. The terms “me” or “my”, “me” or “my” include an authorized representative if I have one. Personally identifiable information is called “PII.” Health plans available through the Marketplace are called Qualified Health Plans or “QHPs”. I understand that: ACCESS AND ITS SUBCONTRACTORS will help me to the best of their ability by telling me about the full range of QHP options and insurance affordability programs for which I may be eligible, and will help me with grievances, complaints, or questions about my health plan, coverage, or a determination under such a plan or coverage, if I want that help. ACCESS AND ITS SUBCONTRACTORS cannot choose a health insurance plan for me. ACCESS AND ITS SUBCONTRACTORS will make sure that my PII is kept private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII and/or the PII of my authorized representative. ACCESS AND ITS SUBCONTRACTORS should not maintain or store any of my PII and/or the PII of my authorized representative, other than this consent form, as a result of carrying out the duties of a Navigator. The duties of a Navigator are explained below. ACCESS AND ITS SUBCONTRACTORS will make sure that any stored PII is kept private and secure. ACCESS AND ITS SUBCONTRACTORS may create, collect, disclose, access, maintain, store, and/or use my PII, and/or the PII of my authorized representative, only in order to perform the duties of a Navigator, and may not re-use that PII for any other purposes [2]. The duties of a Navigator include: Providing information and services in a fair, accurate, and impartial manner. This information should include information about the full range of QHPs that are available and also other health programs like Medicaid and CHIP. The information must be provided in a way that is culturally and linguistically appropriate to the needs of the population being served by the Marketplace, including individuals with limited English. Ensuring that Navigator tools and functions are accessible and usable for individuals with disabilities. Facilitating the selection of a QHP. Providing referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman, or any other appropriate state agency or agencies, for any enrollee with a grievance, complaint, or question about his or her health plan, coverage, or a determination made under such plan or coverage. ACCESS AND ITS SUBCONTRACTORS must also maintain expertise in eligibility, enrollment, and program specifications for QHPs and insurance affordability programs, and conduct public education activities to raise awareness about the Marketplace. ACCESS AND ITS SUBCONTRACTORS should not need to collect, handle, disclose, access, maintain, store and/or use my PII, and/or the PII of my authorized representative for these functions. If ACCESS AND ITS SUBCONTRACTORS does collect, handle, disclose, access, maintain, store and/or use my PII, and/or the PII of my authorized representative, for this function, ACCESS AND ITS SUBCONTRACTORS will keep that PII private and secure. I and/or my authorized representative don’t have to provide ACCESS AND ITS SUBCONTRACTORS with more information than I and/or my authorized representative choose to provide. The help ACCESS AND ITS SUBCONTRACTORS provides is based only on the information I or my authorized representative provide, and if the information given is inaccurate or incomplete, ACCESS AND ITS SUBCONTRACTORS may not be able to offer all the help that is available for my situation. If ACCESS AND ITS SUBCONTRACTORS cannot help me due to a lack of translation services, lack of expertise, or some other barrier, he or she will refer me to another Navigator or in-person assistance personnel, or the federal Marketplace Call Center, who can meet my specific needs. CMS expects that ACCESS AND ITS SUBCONTRACTORS will not charge me a fee for any help provided. I give my permission, or my legal or Marketplace authorized representative acting on my behalf (“authorized representative”), gives his/her permission to ACCESS AND ITS SUBCONTRACTORS to inform me and/or my authorized representative about my health coverage options in the Marketplace to help me apply for and enroll in health coverage through the Marketplace if I choose to do so, and/or to help with a grievance, complaint, or question about my health plan, coverage, or a determination under such a plan or coverage. I understand that in giving this consent, that ACCESS AND ITS SUBCONTRACTORS will need to see or use some of my personally identifiable information in order to provide this assistance. I may cancel my consent in writing at any time and will notify ACCESS AND ITS SUBCONTRACTORS if I choose to cancel my consent. I understand that once I have signed this consent form, I can expect ACCESS AND ITS SUBCONTRACTORS to help me without asking me to sign another consent form. [2] The duties of a Navigator in the Federally-facilitated and State Partnership Marketplaces are stated in: section 1311(i)(3) of the Affordable Care Act; 45 CFR 155.210(e); 45 CFR 155.215(a)(1)(iii); the Cooperative Agreement to Support Navigators in Federally-facilitated and State Partnership Marketplaces funding opportunity announcement (“Navigator FOA”); and the Notice of Award under the Navigator FOA. Please sign and date the form:
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  • PLEASE NOTE: Consumers may sign this consent form themselves, or may choose to have a legal guardian, personal representative, or other delegated representative sign it. Primary Navigator Organization Name: ACCESS Community Health and Research Center Navigator Organization Address: 6450 Maple, Dearborn MI 48126/4301E 14 Mile Sterling Heights MI 48310 Navigator Organization Phone Number:313-216-2200/586-722-6036 Navigator Organization Email: [email protected]