Application Counselor Sponsoring Entity Application
1.
Legal Name of Entity:
Federal tax ID:
Type of Entity:
☐Community Based Organization
☐Health Care Provider
☐Unit of State or Local Government
☐Other Entity, Please Indicate
Entity Contact
Person:
Entity Contact Title:
Entity Contact Email:
Entity Contact Phone
Number:
Entity Address 1:
Entity Address 2:
Entity City:
Entity Zip Code:
Entity State:
Web-Site Address:
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
☐Upper Eastern Shore
☐Western
☐Southern
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Application Counselor Sponsoring Entity Application
3.
Certified Application Counselors: Number of proposed:
Please provide the following information for each proposed certified application counselor
Name
Title
Email
4.
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 dayto-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.
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Application Counselor Sponsoring Entity Application
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.
* Send with this document a letter of support from the Connector Entity you plan to affiliate
11. 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.
*Send with this document the signed and dated Non-Exchange Entity Agreement.
12. Application Counselor Sponsoring Entity Attestation
☐I understand and agree to the terms stated below:
By checking this box, I am indicating my consent 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.
* Send with this document the signed and dated Application Counselor Sponsoring Entity
Attestation
Signature of Entity ACSE Manager:
Date:
SEND ALL Documents to ACSE.CAC@Maryland .gov
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