Request for Application (RFA) »

Application Timelines

1. Request for Applications (RFA) Issue Date:

xx/xx/xxxx

2. Deadline for submission of questions:

xx/xx/xxxx

2a. From the issue date of this RFA until successful Applicants are selected and announced, Applicants may communicate only with the Director of Customer Experience for questions, information and clarification surrounding this RFA. All inquiries should be directed to: RFA Inquiry

3. Responses to questions posted in the RFA area of: YHI Website by:

xx/xx/xxxx

4. Closing date for receipt of application:

xx/xx/xxxx

5. Target date for selection notification:

xx/xx/xxxx

6. Target award date:

xx/xx/xxxx

Information to Prepare for the Application

1. Business History, Population Served, References and Previous Work
2. Proposed Subcontractor Information

Applicant Information

1. Name of entity / organization

2. Entity mailing address

3. Entity street address (if different than mailing address)

3b. City

3c. State

3d. Zip

4. Company Federal ID Number (or SSN, if an individual rather than a company)

5. Name and title of person responsible for signing the agreement

6. Name and title of person acting as the point of contact for the company (if different than the person signing the agreement

7. Contact person direct telephone number

8. Contact person email address

9. Please provide three (3) references – please include their name, title, phone number and email address

PART 1: ORGANIZATION CHARACTERISTICS

1. For organizations, which category best describes you?

*If Other

Please Describe

2. For organizations, how many employees does your organization employ?

PART 2: YOUR POPULATION

Please describe the general population you serve – examples to provide are:

• Geographic region(s): (e.g., Elmore County”)
• Target population(s): (e.g. Homeless, Low Income, etc.)
• Specific needs of your population(s): (e.g., Language or Literacy Barriers)
• Agencies / Organizations You Collaborate With
• Number of Families You Serve Annually
• Number of For-Profit Businesses You Serve Annually (if applicable)
• Number of Non-Profit Businesses You Serve Annually (if applicable)
• Other Targets

Please Describe

Please indicate the likelihood of your target population to enroll in the Idaho Health Insurance Exchange (either via phone or website):

If you perceive your population will need assistance to enroll, please describe what barriers they face to self-enrolling (e.g., lacking computer or internet access, language barriers, literacy difficulties, etc.):

Please indicate the percentage of your target population that fits within the below characteristics (if known):

Receives publicly subsidized medical coverage

Is Uninsured

Is Underinsured

Is insured through individually purchased private insurance

Is self-employed and covered by health insurance

Receives federally subsidized medical coverage (e.g., Medicare, Medicaid, etc.)

Obtains health coverage through an association

Is insured through employer (small group market)

Is insured through employer (large group market)

PART 3: CURRENT AND POTENTIAL CAPACITY TO PROVIDE ASSISTANCE

1. Please indicate the Education and / or Outreach services you currently offer (select all that apply):

In Person

Phone

Describe Education and / or Outreach Services:

2. Please indicate the number of staff trained and currently conducting Outreach and / or Education:

Total # of Employees

Total Staff Hours per week

3. Please indicate the services you currently offer (if applicable) in providing enrollment assistance for subsidized medical coverage (select all that apply):

In Person

Phone

Online