Home › TEST FORM: Application Counselor Sponsoring Entity TEST FORM: Application Counselor Sponsoring Entity Application 1. Legal Name of EntityFederal tax ID:Type of Entity:Community-Based OrganizationHealth Care ProviderUnit of State or Local GovernmentOther Entity (please indicate below)If other entity, please describe:Entity's Contact Name: First Last Entity's Contact Title:Entity's Contact Email: Enter Email Confirm Email Entity's Contact Phone Number:Entity Address: Entity Address Line 1 Entity Address Line 2 Entity City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Entity State Entity Zip Code Entity Website: 2. Please select the region(s) you plan to serve. (Can select more than one. See Map in Program Manual): Capital Central Lower Eastern Shore Southern Upper Eastern Shore Western 3. Number of Proposed Certified Application Counselors:Please download and fill out the Certified Application Counselor Form and email it to: firstname.lastname@example.org. Discuss the qualifications of the Applicant, with regard to: 1) conducting enrollment of individuals into health insurance plans and programs. 2) Having existing relationships with the target population and/or the ability to readily establish such relationships. 3) Experience working with vulnerable and hard-to-reach populations. 4) Filling a need within the region. 5) Experience in working with other State agencies, including Local Departments of Social Services (LDSSs)/Local Health Departments (LHDs).5. Provide the names and relevant experience/qualifications of the key individuals who will be responsible for oversight and management of the certified Application Counselors.6. Discuss ability to perform oversight. Submit a description for overseeing compliance and day-to-day management of employed or engaged certified Application Counselors.7. Describe the Applicant's approach to meeting the Application Counselor Sponsoring Entity program objective of insuring the uninsured. Address the strategic approach and mechanisms/tactics for conducting education and fair and impartial enrollment of individuals into health insurance programs, including Medicaid, Maryland Children's Health Program, Qualified Health Plans and Qualified Dental Plans.8. Describe how the Applicant intends to meet the cultural and linguistic needs of its region with the indicated number of certified Application Counselors. Specifically describe how you will serve non-English speaking people and people with limited English proficiency.9. Address the Entity's plans for quality assurance mechanisms to ensure certified Application Counselors deliver accurate information and high quality services.10. Letter of Support I agree that this letter formalizes the consent from the Connector Entity to support our Entity in consumer enrollment. Email a Letter of Support from the Connector Entity you plan to affiliate to: ACSE.CAC@Maryland.gov11. Non-Exchange Entity Agreement I agree that the Non-Exchange Entity name is the legal name for the organization as recorded with the Department of Assessment and Taxation with the State of Maryland. Download and complete the Non-Exchange Entity Agreement form and email it to: ACSE.CAC@Maryland.gov12. Application Counselor Sponsoring Entity Attestation I understand and agree to the terms stated below. By checking this box, I am indicating my consent to electronically sign this application and warrant that all of the information I have provided is true, complete and accurate. I agree to update any change of address, phone or email within 30 days of the change. I have read, understand and will attest to the Attestation for the Certified Application Counselor Sponsoring Entity, for which I am applying. I understand that I will be required to abide by all applicable state and federal regulations. Download and sign the Application Counselor Sponsoring Entity Attestation and email it to: ACSE.CAC@Maryland.gov.