Certified Application Counselor Designated Organization (CDO) Application
Thank you for your commitment to Illinois residents and to Get Covered Illinois. Please complete and submit this application to become a Certified Designated Organization with Get Covered Illinois. Your application will be reviewed by the Get Covered Illinois Team. The CDO contact person will receive an email if any additional information is needed to complete the application review. When the application is approved, an email will be sent to the CDO contact person with the CDO Agreement for review and signature. This email will contain instructions with the next steps in the CDO process. All sections of the application must be completed in their entirety to be eligible for consideration.
Organization Legal Name
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Organization's Employer Identification Number (EIN)
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Total Number of Planned Individual Certified Application Counselors (CAC)
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Proposed Service Area (Please list the specific regions, cities, and/or counties)
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Organization Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Mailing Address (if same as physical address, please leave blank)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Type (Non-Profit/For-Profit)
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Is the organization a current or past CDO?
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Yes
No
Does the organization participate as a lead grantee or subgrantee in an active Illinois Navigator grant?
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Yes
No
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Application Point of Contact
Please ensure the point of contact is the best individual to reach if the Get Covered Illinois Team has any questions or needs any additional clarification with the application.
Full Name
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Job Title
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
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General Public Contact Information of the Organization
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Website URL
*
Social Media
*
Communities Served (i.e. HIV/AIDS, Elderly, Homeless)
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Additional Organization Details
Please mark all that apply to the organization.
Is the organization a healthcare delivery organization?
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Yes
No
Does the organization currently work with Illinois Healthcare and Family Services (HFS) as a Medicaid Presumptive Eligibility (MPE) provider or Application Agent?
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Medicaid Presumptive Eligibility (MPE)
Application Agent
Both
Neither
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Privacy and Security
Does the CDO have a process in place to protect Personally Identifiable Information (PII)?
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Yes
No
Does the CDO comply with privacy and security standards consistent with CFR 45 155.260, and applicable authentication and data security standards required by federal regulation?
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Yes
No
Provide a summary of your organization’s privacy and security policies and procedures (for example: annual security training, use of firewalls, password protection, incident response plans, etc.).
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Project Site(s)
Please use the information listed below to provide a list of all project site locations and the Certified Application Counselor's (CAC) at each location.
Performance Site Locations. To add additional Performance Site Locations, please click the "+ Add Performance Site" button.
For each Performance Site Location listed above, list all certified application counselors associated with the location.
It may be easier to copy the above information and prepare a word document to copy from and paste in the section above.
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Attestations & Signatures
As the duly Authorized Representative, I agree that the organization will: Maintain a registration process and method to track the training, licensing and participation of certified application counselors; Provide quarterly data and information to the State regarding the number and performance of its certified application counselors and information regarding the customer assistance provided by certified application counselors, upon request, in the form and manner specified by the Get Covered Illinois.
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Yes
No
Conflict of Interest: As the duly Authorized Representative, I certify that the organization and its employees: Do not sell or intend to sell any lines of insurance, including those covered by and adheres to the prohibitions on Certified Application conduct in 45 CFR §155.210(d) while carrying out consumer assistance functions. Do you or any of your employees have any current or former employment relationships in the last 5 years with any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance, including any existing employment relationships between a spouse or domestic partner and any health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance; or Do you or any of your employees have any existing or anticipated financial, business, or contractual relationships with one or more health insurance issuers or issuers of stop loss insurance, or subsidiaries of health insurance issuers or issuers of stop loss insurance?
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Yes
No
If the answer above is "No", please indicate the business and/or financial or contractual relationships below. If "Yes", please indicate n/a.
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The undersigned attests that the above is true and accurate and agrees that if any additional need for disclosures arises after the date of this signature, the organization shall immediately make a full disclosure in writing to Get Covered Illinois of all additional information.
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Yes
No
Mandatory Disclosures: Disclose all information related to violations of state or federal criminal law involving fraud, bribery, or gratuity violations that may affect the State’s decision to approve CDO status. If none, please indicate with n/a
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Assurances: As the duly Authorized Representative, I am aware that submission of the accompanying application constitutes the creation of a public document that may be made available upon request at the completion of the application process. In addition, I certify that the organization: Will give the Get Covered Illinois, or its authorized representatives, access to and the right to examine all records, books, papers, or documents related to the application. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents a real or perceived personal or organizational conflict of interest, or personal gain.Will comply with all federal and state statutes and regulations relating to program operation and non-discrimination. These include but are not limited to: Federal regulations governing this program can be viewed online at the following location: eCFR :: 45 CFR Part 155 Subpart C -- General Functions of an Exchange See 155.205 and 155.210 for program standards See 155.215 for training and conflict-of-interest standards See 155.260 for privacy and security requirements State regulations governing this program can be viewed online at the following locations: 50 Ill. Adm. Code 4500.140 for general conditions (selected sections are included below) 50 Ill. Adm. Code 4515 for training standards, prohibited conduct, and other conditions for certification
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Yes
No
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Program Information
Section 4500.140 State Awards for Navigators and In-Person Counselor Organizations, and Certifications for Certified Application Counselor Organizations and Certified Application Counselors Approvals of CDO applications may be revoked if training and licensing requirements are not fulfilled within 90 days of approval. Failure to respond to questions from the Get Covered Illinois Team or return of a signed CDO Agreement may result in an automatic withdraw of application from the CDO program. The CDO organization contact will receive a welcome email upon review and approval; this email will contain a CDO agreement for signature and next steps regarding training and certification. Notification of approvals will come from GCI.CDO@Illinois.gov.
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Authorized Representative:
The Authorized Representative, or Authorized Organizational Representative (AOR), is the designated representative of the applicant organization with authority to act on the organization’s behalf regarding the application.
Authorized Representative Name
First Name
Last Name
Authorized Representative Title
*
Authorized Representative Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Representative Email Address
*
example@example.com
Authorized Representative Signature
*
Date Signed
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-
Month
-
Day
Year
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