We have developed a set of easy-to-use forms for marketplace navigators to help gather the vital information you need. You are free to download and adapt these forms as required.
Just click below to view/download individual pdf forms, in basic format for printing, and also as fillable versions for onscreen use.
If you have comments or suggestions on these forms please contact the O&E team.
Additional forms and useful information
Model Authorization Form for Certified Application Counselors (CACs) in a Federally-facilitated Marketplace1 (Marketplace)
A model form for CACs to acknowledge their responsibilities working in the Marketplace
Click image to view / download
Requirements and Best Practices for Assisters on Providing Remote Consumer Assistance
This job aid provides information and guidance Navigators and certified application counselors (CACs) (collectively, assisters) need to know in order to provide remote help securely to consumers applying for and enrolling in Marketplace coverage.
Click image to view / download
CDO Application Open Season
The Certified Application Counselor Designated Organization (CDO) Application web form is now live and will remain available year-round!
If you do not have a Regtap account with CMS you will need to create one to be able to access the CAC training and webinars. https://regtap.cms.gov/reg_tips.php
CDO Renewal Job Aid
Just like Fall, the cooler months bring the process of renewing your CDO agreements. If you have received a notice from CMS stating that this is your renewal time, please check this resource for assistance. (Remember, you only renew every two years).
Complex Case Form
A Complex Case is a case involving a single consumer or tax household where the assister has been unable to resolve a specific issue on the consumer or tax household’s application for Marketplace coverage. Complex cases are not policy questions or general questions about the Marketplace application. The Complex Case web form allows assisters to submit a Complex Case for investigation. The form also allows assisters to report when a consumer communicates that they have been enrolled in a health plan without their knowledge or consent or their health plan has been changed without their knowledge or consent.
Access the Complex Case User Guide here
Access the Complex Case Submission web form here
You can access live assistance by calling 1-800-318-2596.
If you are utilizing the complex case form to report when a consumer communicates that they have been enrolled in a health plan without their knowledge or consent or their plan has been changed without their consent it is also recommended that you file a complaint with the Indiana Department of Insurance.
Click here to visit IDOI complaints page
Visit our Outreach and Enrollment pages for more information
