Healthcare.oregon.gov



SUBMISSION FORMPlease return all submission documents to: dcbs.opportunity@Business Information of Proposers or Proposing TeamBusiness nameDBA: Address (street address)Address (Mailing Address)Primary storefront county of operationPhone #WebsiteLicense # or NPNYear business was establishedNumber of PY 2019 QHP enrollmentsStorefront Locations in other countiesProposer Contact information: Name:Title:Phone:Email:List Agents below who were affiliated with your agency during PY 2019 open enrollmentNameNPNStorefront LocationYears of Exp. Total Number of PY 2019 QHP Enrollments Returning for PY 2020 (Y/N)List any new Agents below who will be participating in the Program for PY 2020NameNPNStorefront LocationYears of ExperienceTotal Number of PY 2019 QHP EnrollmentsAGENT QUALIFICATIONS (50 points)Provide a summary of business offerings, agent capabilities/qualifications, size of agency, community served, etc. (maximum 500 words):Insert hereIf applicable, provide a summary of previous Program Participation and how that experience will be useful/helpful in future participation? (maximum 500 words) Insert hereProvide a short narrative summary explaining why your agency would be a great fit for the Statewide Partner Agent Program (maximum 500 words):Insert hereENROLLMENT AND OUTREACH (25 points)How man appointments do you average each day of open enrollment?Insert hereWhat marketing/outreach activities have you employed in previous open enrollment periods that you feel are most successful, if applicable. Insert hereDescribe your presence on social media, if applicable. Include number of “followers”:Insert hereList the types of individual health insurance products you market or sell. For example, qualified health plans, specific disease policies, non-QHP health benefit plans, etc.Insert hereState the percentage of your individual health insurance business for each product listed in response to 2.4 above.Insert hereDo you sell any “health insurance-like” products that are not regulated by the state of Oregon? If so, describe those products, how and to whom they are marketed.Insert hereSTRATEGIES (25 Points)Using the template below, outline your proposed plan to use grant money to fund a Storefront enrollment center, as well as for the outreach strategies you plan to utilize as part of this grant. Proposed Strategy Budget: Based on the example below, provide an overview of your proposed strategies as well as the proposed budget for each.EXAMPLE – Enrollment and/or Outreach-specific (actual dollar amounts will vary):BUDGETStrategy #1Hire weekend data entry clerk$2,500Strategy #2Place ad in local paper to drive business to Storefront$750Strategy #3Overtime costs $1,000Strategy #4Upgrade internet service for 3-month period$750TOTAL$5,000Complete the following section: Refer to Section 8.3.2 of RFGP for your estimated award tier for proposed budget.Proposed Strategies:Proposed BudgetStrategy #1Strategy #2Strategy #3Strategy #4Strategy #5Strategy #6Strategy #7Total Proposed Budget:Strategy Specifications: Provide specifics of each proposed strategy included above. Include what tactics are proposed and who the intended target audience will be. EXAMPLE – Outreach specific:Strategy #1: AdvertisingTacticsCreate digital and print ads Advertise using boosted Facebook postsAdvertise in popular brewery tour guidebookAudience(s)General public26-year-olds phasing out of guardians’ insuranceStrategy #2: Earn press coverageTacticsCreate a press release about open enrollment deadlines (using local data) and pitch local mediaHost Q&A session on local radio programAudience(s)General publicSubsidy-eligible public Complete the following section: Proposed strategy specifications should align with the proposed strategy budget in Section 3.1. Additional sections may be added if necessary.Strategy #1: TacticsAudience(s)Strategy #2:TacticsAudience(s)Strategy #3:TacticsAudience(s)Strategy #4:TacticsAudience(s) SPECIAL CONSIDERATION (up to 50 total points of extra credit)Do you meet any of the following criteria for special consideration? Select any that apply:? I have demonstrated deep community involvement (Community involvement beyond healthcare/health insurance, including, but not limited to serving on a local council, coaching Little League). Describe: Please attach at least one letter of reference in support of this claim.Insert here? I have multiple language skills (e.g., speak Spanish, Chinese, Russian or another language in addition to English, but not through a 3rd party). Describe the language skills and relevance within your community/service area: Insert here? I have existing relationships with OHP assisters. Describe the extent which you work directly with OHP assisters, as well as your work doing direct enrollments through the OHP ONE system: Insert herePlease attach at least one letter of reference from an OHP assister in support of this claim.? I have demonstrated cultural competencies (e.g., experience working with any underserved populations, including, but not limited to LGBTQ populations, immigrant populations or communities of color. Describe: Insert here? Describe your health insurance book of business (e.g., Marketplace, direct, small group, Medicare)Insert here Is there any additional information you would like to share to aid in the evaluation of your proposal?Insert here_____________________________________________________________________________________Proposer SignatureDate ................
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