Exhibit_4_-_Navigator_Program_Application_Form.pdf

Oklahoma Health Insurance Marketplace: PY 2027 Navigator Program Application Form Instructions: Complete the information below to provide details about your organization and proposed project goals for the 12-month period (September 2026 – August 2027). All responses should align with the Navigator Program Standards as outlined in 45 CFR §155.210 and Oklahoma Administrative Code 365: 10-31.

A. Organization Information

1. Organization Legal Name

2. Organization Employer Identification

Number (EIN)

3. Organization Type (e.g., provider, community or consumer-focused nonprofit, or other entity that meets requirements)

4. Website URL

5. Total Number of Planned Individual

Navigators

6. Number of Physical Locations

7. Addresses

a. Primary Physical Address Street City, State Zip / Postal Code County

b. Mailing Address (complete only if different from above; P.O. Boxes allowed) Street City, State Zip / Postal Code

c. Additional Project Site Location(s) (submit an additional page with additional project site location(s), if needed) Street City, State Zip / Postal Code County

8. Navigator Entity Consortium?

(Yes/No)

If yes, enter the Sub-Recipient Organization Name(s) (Refer to the Navigator Program Request for Proposal for additional details)

9. Consortium Information If applicable, describe the consortium structure and participating organizations.

Responses must address each of the following elements:

• Participating organizations: Identify each organization included in the consortium.

• Roles and responsibilities: Describe the role of each organization and its primary responsibilities.

• Governance structure: Explain how the consortium is governed, including decision-making authority and oversight.

• Work coordination: Describe how work is coordinated across organizations, including communication, reporting, and collaboration processes.

If this question does not apply, state “Not applicable.”

B. Point of Contact: The Point of Contact is the assigned project lead responsible for overseeing and coordinating the work described in this form.

10. Point of Contact Last Name First Name

11. Job Title

12. Telephone Number

13. Email Address

C. Authorized Organizational Representative: The Authorized Organizational Representative is the designated representative of the Navigator Entity with authority to act on the organization’s behalf in matters related to the award.

14. Authorized Organizational Representative Last Name First Name

15. Job Title

16. Telephone Number

17. Email Address

Project Description

Navigator Entity applicants must answer the following questions to describe their Navigator Program throughout the performance period.

A. Proposed Service Area Define the geographic area where services and outreach will be conducted. Include all applicable counties, cities, regions, and/or zip codes.

B. Target Populations and Communities Served Identify the priority population(s) you intend to serve. For each priority population, provide the estimated number of consumers you expect to reach and any relevant geographic, demographic, and socioeconomic characteristics.

C. Application and Enrollment Strategy Target number of consumers assisted with their Marketplace application, plan shopping navigation, and/or enrollment or re-enrollment in a QHP.

This may also include assisting consumers with Marketplace exemptions, coverage appeals, and tax forms.

Target number of consumers assisted who completed enrollment or re-enrollment in a QHP.

This may include enrollments completed online, via phone, or with paper applications.

This goal’s target number should be a subset of the target number above.

Describe how the organization helps consumers understand eligibility and coverage options, enroll, and update applications. Response must include how the organization plans to meet targets.

(Minimum required word count: 250 words)

D. Outreach and Education Strategy Target number of consumers assisted with understanding basic concepts and rights related to health coverage.

This may include educating consumers on health insurance literacy, billing and payment processes, locating providers, Marketplace or Medicaid coverage, accessing preventative health services, etc.

Target number of outreach activities See Section 2.2 of the RFP for the definition of outreach activities.

Target number of educational materials developed.

This may include presentation materials, flyers, handouts, etc. This should reflect the number of unique materials developed, not the number of materials distributed (e.g., a handout provided to 20 consumers counts as 1 educational material, rather than 20).

Describe the outreach and education approach, including methods, target audiences, and key messages. Response must include how the organization plans to meet targets.

E. Referral Plan Anticipated number of consumers connected to additional support This may include referrals to agents/brokers, Medicaid/CHIP, Medicare, insurance companies, Marketplace Call Center, tax professionals, or other assistance groups.

Describe how consumers are referred to other programs or community resources when needs extend beyond the organization’s services.

F. Accessibility Approach Explain how services will be accessible to consumers with disabilities and consumers with language and literacy needs. Include accessibility methods offered, language and literacy support available, how consumers request accommodation, and who is responsible for providing support.

(Minimum required word count: 150 words)

G. Privacy and Security of Consumer Personally Identifiable Information (PII) Describe the Navigator’s plan to protect consumers’ PII, in accordance with Oklahoma privacy and security standards, including ongoing monitoring consistent with 45 CFR §

155.260. Include compliance approach and procedures for the following:

• Screening and training personnel with access to PII and other sensitive data

• Granting and revoking access to PII

• Obtaining, documenting, and securely storing consumer consent

H. Personnel Qualifications List and describe key staff qualifications and relevant experience of key staff and/or personnel contracted to support the proposed Navigator activities (and, if applicable, budgeted roles). For each key staff include relevant qualifications, credentials, and experience, primary responsibilities, and how the role aligns with proposed activities.

I. Navigator Staffing and Onboarding Plan Describe the organization’s approach to staffing/contracting and onboarding Navigators.

• Provide the anticipated number of Navigators for the performance period.

• Outline the approach and timeline for recruiting, hiring, onboarding, and training new staff, contractors, or volunteers to meet project milestones.

• Address how the organization plans to ensure Navigators maintain registration and certification status.

J. High-Level Budget Description In line with the detailed budget submitted for the performance period, provide a brief overview of the project’s projected costs and planned funding strategy, highlighting priority areas and any assumptions used to estimate the budget.

Additional Information, Assurances, and Signature

A. Additional Information Provide any additional information the organization would like to share.

B. Assurances As the duly Authorized Organizational Representative (AOR), I am aware that submission to the Oklahoma Insurance Department of the accompanying documentation constitutes the creation of a public document that may be made available upon request at the completion of the award process. This may include the completed Navigator Program Application Form, Business Assessment & Mandatory Disclosure of Risk Form, Detailed Budget, and any additional materials.

In addition, I certify that the Navigator Entity organization:

• Has legal authority to apply for the funds made available under the requirements of the documentation, and has the institutional, managerial, and financial capacity (including funds sufficient to pay the non-State share of project costs, as appropriate) to ensure proper planning, management and completion of the project described in this form.

• Will give the Oklahoma Insurance Department, or its authorized representatives, access to and the right to examine all records, books, papers, or documents related to the award, and will establish a proper accounting system in accordance with Generally Accepted Accounting Principles (GAAP).

• 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. This means that the Navigator

Entity did not have any involvement in the preparation of the Navigator Program materials, including the Navigator Program Application Form or Navigator Program RFP, development of specifications or requirements, or the evaluation of the submitted forms.

• Will maintain necessary operational and financial systems to effectively manage and safeguard award monies and data.

• Will comply with all federal and state statutes and regulations relating to non-discrimination. These include but are not limited to: 1) Title VI of the Civil Rights Act of 1964 (P.L. 88-352;34 CFR Part 100) which prohibits discrimination based on race, color or national origin; 2) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794; 34 CFR Part 104), which prohibits discrimination based on handicaps and the Americans with Disabilities Act (ADA), 42 U.S.C.

12101 et seq.; 3) Age Discrimination Act of 1975, as amended (42 U.S.C. 6101 et.

seq.; 45 CFR part 90), which prohibits discrimination on the basis of age; and associated executive orders pertaining to non-discrimination on public contracts;

and 4) Federal Equal Employment Opportunities Act.

• Will comply with all applicable federal and state laws and regulations.

• Has included a statement of explanation regarding any and all involvement in any litigation, criminal or civil.

• Attests that the Navigator Entity and all subrecipients are not presently debarred, proposed for debarment, declared ineligible, or voluntarily excluded.

• Understands that unresolved monies owed to the federal agencies or the State of

Oklahoma may preclude the receipt of this award.

• Understands that any false, fictitious, or fraudulent statements or claims may subject the organization and/or individual to criminal, civil, or administrative penalties.

• Attests that all statements contained within the submitted Oklahoma Marketplace Navigator Program documents, including the Navigator Program Application Form, Business Assessment and Mandatory Disclosure of Risk Form, Detailed Budget, and any additional documents are true, complete, and accurate to the best of my knowledge.

• Certifies that the organization and its subrecipients will comply with all the assurances above.

• Certifies that the organization and its subrecipients have read the Navigator Program Request for Proposal in full and will comply with program requirements.

• Certifies that the organization and its subrecipients have read the state and federal regulations pertaining to Navigator Programs.

AOR Name AOR Signature

Date

Oklahoma Health Insurance Marketplace: PY 2027 Navigator Program Application Form