AGREEMENT RE FEDERALLY FACILITATED EXCHANGES WITH CENTERS FOR MEDICARE AND MEDICAID.PDF

AGREEMENT BETWEEN THE CENTERS FOR MEDICARE & MEDICAID
SERVICES AND CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH A FEDERALLY-
FACILITATED EXCHANGE 15 OPERATING
T -HIS AGREEMENT ("Agreement") is entered into by and between THE CENTERS FOR
MEDICARE & MEDICAID SERVICES ("CMS"), as the Party (as defined below) responsible
for the management and oversight of the Federally-facilitated Exchanges ("FFEs"), and
Maricopa County Department of Public Health, Healthcare for the -Homeless, an organization
that has been designated by CMS as a Certified Application Counselor Designated Organization
(hereinafter referred to as "CDO") in Arizona, a State/States in which an FFE is operating. CMS
and CDO are hereinafter sometimes referred to as "Party" or, collectively, as the "Parties."
WHEREAS:
I. Pursuant to 45 CFR 155.225(b), to facilitate the operation of the FFE, CMS may
designate an organization to certify its staff members or volunteers to act as Certified
Application Counselors (CACs).
2. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative( s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QHP through the FFE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
3. Pursuant to 45 CFR 155.225(b)(1)(i), to be designated as a CDO, an organization must
enter into an agreement with the Exchange to comply with the standards and
requirements of 45 CFR 155.225, including but not limited to 45 CFR 155.225(d)(3)-(5).
4. To facilitate the operation of the FFE, CMS has determined that it would be beneficial to
permit CDO, and the staff members and volunteers CDO certifies as CACs, to create,
collect, disclose, access, maintain, store, or use Personally Identifiable Information
("PII") from CMS, Consumers, Applicants, Qualified individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), to the extent that these activities are necessary to carry out the
Authorized Functions that the Affordable Care Act ("ACA"), implementing regulations,
and this Agreement permit.
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5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and use
PII from CMS, Consumers, Applicants, Qualified Individuals, Qualified Employees,
Qualified Employers, and Enrollees, or their legal representative(s) or Authorized
Representative(s), in order to perform the Authorized Functions described in Section 111.2
of this Agreement.
6. 45 CFR 155.260(b) provides that an Exchange must require the same or more stringent
privacy and security standards as are established and implemented for the Exchange
under 45 CFR 155.260(a), as a condition of contract or agreement with Non-Exchange
Entities, and CDO is a Non-Exchange Entity.
7. CMS, in the administration of the FFEs, has adopted privacy and security standards
concerning PIT, as set forth in the attached Appendix A, "Privacy and Security Standards
and Implementation Specifications for Non-Exchange Entities," which is hereby
incorporated by reference. Compliance with this Agreement satisfies the requirement
under 45 CFR 155.225(d)(3) to comply with applicable authentication and data security
standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
II. OBLIGATIONS AND CONDITIONS. To carry out the functions authorized by 45 CFR
155.225, and as a condition of its designation as a CDO by the FFE, CDO agrees to:
1. Certify one or more individual staff members and/or volunteers of the CDO to serve as
CACs who are authorized to facilitate the efficient operation of one or more specific
FFEs. Such certification shall include the assignment of a unique CAC identification
number, as described in Section 113 of this Agreement, and the issuance of a CAC
Certificate to each individual staff member or volunteer that is certified by the CDO to
serve as a CAC. CAC Certificates must include the staff member or volunteer's name
and unique CAC identification number;
2. Prior to certifying any staff member or volunteer to serve as a CAC, do all of the
following:
a. Ensure that each such staff member or volunteer seeking certification as a CAC
completes CMS-approved training regarding Q1IP options, Insurance
Affordability Programs, eligibility, and benefits rules and regulations governing
all Insurance Affordability Programs operated in the state, as implemented in the
state, and completes and achieves a passing score on all CMS-approved
certification examinations, prior to functioning as a CAC;
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b. Require each. such staff member or volunteer seeking certification as a CAC to
enter into a written, signed agreement with the CDO that requires the individual
staff member or volunteer seeking certification as a CAC to:
i. Register for CMS-approved training using his or her unique CAC
identification number and the namethat will appear on both his or her
CAC Certificate and Training Certificate, complete the training and
examination requirements described in Section!] .2.a. of this Agreement,
and provide proof in the form of his or her Training Certificate to the CI. 0
that he or she has fulfilled the training and examination requirements;
ii. Disclose to the CDO and to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these
individuals' legal representative(s) or Authorized Representative(s), any
relationships the CAC has with QI-IPs or Insurance Affordability
Programs, or other potential conflicts of interest, and, if the CDO elects to
comply with Section 11.5 of this Agreement by requiring CACs to do so,
disclose to any Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) any potential
conflicts of interest of the CDO;
Comply with the FFE's Privacy and Security Standards and
Implementation Specifications for Non-Exchange Entities, which was
drafted in conformance with 45 CFR 155.260, and applicable
authentication and data security standards, through provisions that impose
the same duties and obligations as those imposed on CDO by Section In
and Appendix A of this Agreement;
iv. Act in the best interest of any Consumers, Applicants, Qualified
individuals, Enrollees, Qualified Employees, or Qualified Employers that
he or she assists;
v. Either directly or through an appropriate referral to a Navigator or non-
Navigator assistance personnel authorized under 45 CFR §§ 155.205(d)
and. (e) or 155.210, or to the Exchange call center authorized under 45
CFR -§ 155.205(a), provide information in a manner that is accessible to
individuals with disabilities, as .defined by the Americans with Disabilities
Act, as amended, 42 LISC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
vi. Inform Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers, and/or these individuals' legal
representative(s) or Authorized Representative(s) of the functions and
responsibilities of Certified Application Counselors. CDO and its staff
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members and/or volunteers may use the model form provided. by CMS and
appended hereto and referred to as Appendix E to fulfill this requirement;
vii. Prior to creating, collecting, disclosing, accessing, maintaining, storing, or
using any PH of Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, Qualified Employers, and/or their legal
representative(s) or Authorized. Representative(s), obtain the authorization
required by 45 CFR 155.225(1) and section. 1L8 of this Agreement
(hereinafter referred to as "authorization") to: create, collect, disclose,
access, maintain, store, and. use PH of such person(s) to carry out the
Authorized Functions listed at Section 111.2 of this Agreement. This
authorization may be obtained either directly from the Consumer,
Applicant, Qualified individual, Enrollee, Qualified Employee, and/or
Qualified Employer, or through such person(s)' legal representative(s) or
Authorized Representative(s). CDO and its staff members and/or
volunteers may use the model forin provided by CMS and appended
hereto and referred to as Appendix E to fulfill this requirement. This
authorization is separate and distinct both from any authorization obtained
pursuant to section 111.7 of this agreement and from the informed consent
referenced in Appendix A at 3(a);
viii. Maintain a record of the authorization provided under Section II.2.b.vi.i;
ix. Permit the Consumer, Applicant, Qualified. Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section 11..2.b.vii at any time;
x. Not impose any charge or fee on Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Em:ployees, and Qualified Employers,
and/or these individuals' legal representative(s) or Authorized
Representative(s) for application or other assistance related to the
Exchange;
xi. Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these
individuals' legal representative(s) or Authorized Representative(s), the
CAC Certificate provided by the CDO evidencing the staff member's or
volunteer's certification as a CA.0 each time the staff member or volunteer
assists any Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified. Employers, and/or these individuals'
legal representative(s) or Authorized .Representative(s);
xii. Provide information to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these
individuals' legal representative(s) or Authorized Representative(s) about
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the full range of QHP options and insurance Affordability Programs for
which they are eligible;
xiii. Assist Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers, and/or these individuals' legal
representative(s) or Authorized Representative(s) in applying for coverage
in a QHP through the Marketplace and for Insurance Affordability
Programs;
xiv. Help to facilitate enrollment of eligible Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers in
QI-IPs and Insurance Affordability Programs, either directly or through
these individuals' legal representative(s) or Authorized Representative(s);
xv. Provide his or her uniqu.e CAC identification number to any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, and
Qualified Employer, and/or these individuals' legal representative(s) or
Authorized Representative(s) assisted by the staff member or volunteer,
and include his or her unique CAC identification number on any
application that is fully or partially completed in connection with the staff
member or volunteer's assistance for that individual;
xvi. Upon termination or nonrenewal of CAC's agreement with CDO, or
withdrawal of designation from CDO or withdrawal of certification from
CAC, immediately cease holding himself or herself out as a CAC to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
and Qualified Employer, and/or these individuals' legal representative(s)
or Authorized Representative(s), and immediately cease providing
certified application counselor CA.0 services to the public;
xvii. Not sell or otherwise transfer information. provided by Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or
Authorized Representative(s) to any person or entity other than such
actions as are specifically permitted by this Agreement; and
xviii. Not collect or otherwise maintain information provided by Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or
Authorized Representative(s), except as specifically provided for in this
Agreement.
Maintain a registration process and method to track the performance of CACs. This
tracking method shall include assigning a unique CAC identification number to each staff
member or volunteer certified by the CD() to serve as a CAC, which shall consist of an
identification number that -CMS assigns the CDO and that identifies the CDO, followed
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by the unique identification number assigned to each individual staff member or
volunteer by the CDO.
4. Upon. request, provide to CMS the names and CAC identification numbers assigned by
the CDO of all staff members and volunteers that have been certified by the CDO to
serve as CACs;
Establish procedures to directly, or, if the CDO so elects, through its CACs, disclose all
potential conflicts of interest of the CDO to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or these
individuals' legal representative(s) or Authorized Representative(s) prior to providing
assistance to any such individuals, including any relationships the CDO has with QIHIPs or
Insurance Affordability Programs, or other potential conflicts of interest;
6. Act in the best interests of the Consumers, Applicants, Qualified individuals, Enrollees,
Qualified Employees, and Qualified Employers assisted by the C )0 and by the staff
members and volunteers it has certified as CACs;
7. Either directly or through an appropriate referral to a Navigator or non-Navigator
assistance personnel. authorized under 45 CFR §§ 1 .55.205(d) and (e) Or 155.210, or to the
Exchange call center authorized under 45 CFR § 155.205(a), provide information in a
manner that is accessible to individuals with disabilities, as defined by the Americans
with Disabilities Act, as amended, 42 USC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
8. Establish procedures to ensure, pursuant to 45 CFR 155.225(f), that Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Are informed of the functions and responsibilities of CACs. CDO and its staff
members and/or volunteers may use the model form provided by CMS and
appended hereto and referred to as Appendix E to fulfill this requirement;
b. Provide authorization, before CDO or any of CDO's staff members and/or
volunteers collect, disclose, access,.maintain, store, or use any of their PII, for
CDO and CDO' s staff members and volunteers to: create, collect, disclose,
access, maintain, store, and use their P1.1 to carry out the Authorized Functions
listed at Section 111.2 of this Agreement. This authorization may he obtained
either directly from the Consumer, Applicant, Qualified individual, Enrollee,
Qualified Employee, and/or Qualified Employer, or through such person(s)'
representative(s) or Authorized Representative(s). CDO and its staff members
and/or volunteers may use the model form provided by CMS and appended hereto
and referred to as Appendix. E to fulfill, this requirement. This authorization is
separate and distinct both from any authorization obtained pursuant to section
H1..7 of this agreement and from the informed consent referenced in Appendix . A
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at 3(a), CDC) must. ensure that it or its staff members and/or volunteers maintain a
record of it; and
c. May revoke at any time the authorization provided pursuant to 155.225(0.
9. Oversee and monitor any staff member or volunteer it certifies as a CAC to ensure that
each CAC complies with all requirements of the program specified in 45 CFR 755.225,
and with all requirements set forth in Section. 11.2 of this Agreement.
10. Establish and comply with procedures to do the following:
a. As soon as possible, but in no event later than 20 Days after the triggering event
(identification or notification of noncompliance), withdraw the certification of any
staff member or volunteer that has been certified by the CDO if the CD() learns or
is notified by CMS that the staff member or volunteer has failed to -comply with
the terms and conditions of the CAC's agreement with the CDO or with the
requirements of 45 CFR 155.225;
b. Protect any Pil of Consumers, Applicants, Qualified individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals' legal
representative(s) or Authorized Representative(s) created, collected, disclosed,
accessed, maintained, stored, or used by any CAC whose certification is
withdrawn, by complying with the obligations set forth in Section VI of this
Agreement;
c. As soon as possible, but in no event later than 20 Days after the CDO learns that
any staff members or volunteers who have been certified as CACs are out of
compliance with the terms and conditions of.the agreement required by Section
II.2.b of this Agreement, or with any of the requirements of 45 CFR 155.225, or
upon notification from CMS that the CDO must withdraw certification from any
specific staff member and/or volunteer, notify the certified staff member or
volunteer that he or she must, immediately upon receipt of this notice, cease
holding out him- or herself as a CAC to any Consumer, Applicant, Qualified
Individnal, Enrollee, Qualified Employee, and/or Qualified Employer, and/or
these .individuals' legal representative(s) or Authorized Representative(s), and
cease providing CAC services to the public;
d. As soon as possible, but in no event later than 20 Days after notification from.
CMS that the CDO' s designation as a CDO has been withdrawn, ensure that all
staff members and. volunteers refrain from holding themselves out as CACs and
refrain from providing CA.0 services to the public,
11. Not impose any charge on Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified . Employers, and/or these individuals' legal
representative(s) or Authorized Representative(s) for application or other assistance
related to the Exchange;- and
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12. Comply with the privacy and security standards adopted by the FFE pursuant to 45
C.F.R. § 155.260(b), and applicable authentication and data security standards, in the
manner set forth in section III and Appendix A of this Agreement;
13. Directly, or through its staff or volunteers it certifies as CA Cs, provide any and all
services in connection with the obligations and conditions in this Agreement, as
described in Section IL 1-13 and III of this Agreement, without compensation (excluding
wages earned by employees of the CDO for work performed by such employee on behalf
of its CDO employer), and hereby waive its rights to any compensation from the
Government of the United States of America to which it may be entitled under law.
Ilk OBLIGATIONS RELATED TO THE PRIVACY AND SECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION.
1. CDO hereby acknowledges and agrees to accept and abide by the standards and
implementation specifications set forth below and in Appendix A, "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities," which is
incorporated by reference in this Agreement, when engaging in any activity as a CDO
pursuant to 45 CFR 155.225. CDO is thereby bound to strictly adhere to the privacy and
security standards, and to ensure that its Workforce that creates, collects, accesses, stores,
maintains, discloses, or uses PH, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the efficient
operation of the FFE.
2. Authorized Functions. CDO may create, collect, disclose, access, maintain, store, and
use PH of Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees,
and Qualified Employers, or these individuals' legal representative(s) or Authorized
Representative(s) in order to:
a. Provide information to these persons about the full range of QIIP options and
Insurance Affordability Programs for which these persons are eligible;
b. Assist these persons with applications for coverage in a QHP through the FFE and
for Insurance Affordability Programs;
c. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
d. Perfotiu other functions authorized under 45 CFR 155.225, including functions
substantially similar to those enumerated above, and such other functions that
may be approved by CMS in writing from time to time.
3. PIT Received. Subject to the terms and conditions of this Agreement and applicable laws,
in performing the tasks contemplated under this Agreement, CDO, may create, collect,
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disclose, access, maintain, store, and use the following data and PII from Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, start and end
dates
Applicant QI-IP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amount
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant (MP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birthdate
Contact Telephone number
Contact Email
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FFE Applicant ID
FEE 'Member ID
Issuer Member ID
Net premium amount
Premium Amount, start and end dates
Pregnancy indicator
Special enrollment period reason
Subscriber Indicator and. relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
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4. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining, storing, or
using any NI from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers, and/or these individuals' legal representative(s) or
Authorized Representative(s), CDO will ensure that the CAC obtains the authorization
required under Section 11.8 of this Agreement to create, collect, disclose, access,
maintain, use, or store their PH to carry out the Authorized Functions listed at Section
11I.2 of this Agreement, and will permit the authorization to be revoked at any time. CDO
and its staff members and/or volunteers may use the model form provided by CMS and
appended hereto and referred to as Appendix E to fulfill this requirement. This
authorization is separate and distinct from any authorization obtained pursuant to section
111.7 of this agreement and the informed consent referenced in Appendix A at 3(a). The
CDO should ensure that a record of the authorization provided is maintained in a manner
consistent with the privacy and security standards set forth in Appendix A.
Collection of PH. PIT collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'. legal
representative(s) or Authorized Representative(s), may be used only for the Authorized
Functions specified in Section 111.2 of this Agreement. Such information may not be
reused for any other purpose,
6. Storing PH, Other than documentation related to the authorization required by Section
111.4 above, CDO is not expected or required to maintain or store any of the above listed
Pll as a result of carrying out the Authorized Functions specified in Section 111.2 above.
To the extent that a CDO does maintain or store PI1, such as documentation related to the
authorization required by Section 11.1.4, it must agree to comply with all provisions of this
Agreement and Appendix A that apply to the maintenance or storage of PH.
7. Collection and Use of Information Provided Under Other Authorities, This Agree]. e
does not•preclUde CDO from separately collecting information from Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and Qualified •
Employers, and/or these individuals' legal representative(s) Or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such non-
FFE information obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must be .separately collected and stored from
any PIE collected in accordance with this Agreement. Any authorization for collection
and use of PII under this provi.sion is separate.and distinct from the authorization
obtained pursuant to Section 111.4 above and II.2.b.vii and 11.8, and should be obtained
and maintained separately from that authorization.
8„Abilitv ofconsumer to Limit Collection and Use. CDO agrees to allow the Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, and Qualified Employer,
directly OF through these individuals' legal. representative(s) or Authorized
Representative(s), to limit the CDO's creation, collection, use, maintenance, storage, and
disclosure of their PH to the sole purpose•of obtaining CD0's assistance for FFE
purposes, and for performing Authorized Functions specified in Section 111.2 of thi.s
Agreement.
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IV, EFFECTIVE - DATE; TERM AND RENEWAL.
a. Effective Date and Term. This Agreement becomes effective on the date the last
of the two Parties executes this Agreement and ends one year from the effective
date.
h. Renewal, This Agreement will automatically renew for subsequent and
consecutive one (1) year periods upon the expiration of this agreement unless, in
the sole and absolute discretion of CMS, thirty (30) Days' advance written notice
of nonrenewal is provided by CMS to CDO, or the Agreement is terminated
pursuant to Section V of this Agreement.
V. TERMINATION.
a. Termination without Cause. Either Party may terminate this Agreement without
cause and for its convenience upon at least thirty (30) Days' prior written notice
to the other Party. Such notice will include the effective date on which the
organization will no longer have its staff members or volunteers provide CAC
services. This Agreement shall automatically terminate at the end of its term or in
connection with the rejection of an amendment as provided for in Section VII,h of
this Agreement.
b. Termination with Cause. CMS may terminate this Agreement for cause, as
follows:
1. Termination with Notice, This Agreement shall terminate immediately
upon CMS's withdrawal of CDO' s designation as a CDO. CMS may
terminate this Agreement upon fourteen (14)-Days' written notice to
CDO if CDO materially breaches any term of this Agreement as
determined at the sole but reasonable discretion of CMS, unless CDO
commences curing such breach(es) within such ,14-Day period to the
reasonable satisfaction of CMS, and thereafter diligently prosecutes such
cure to completion. The 14-Day notice from CMS shall contain a
description of the material breach, whereupon CDO shall have seven (7)
Days from the date of the notice in which to propose a plan and a time
frame to cure the material breach, which plan and time frame may be
rejected, approved or amended in CMS's sole but reasonable
discretion. Notwithstanding the foregoing, CDO shall be considered in
"Habitual Default" of this Agreement in the event that it has been served
with a 14-Day notice under this subsection more than three (3) times in
any calendar year, whereupon CMS may, in its sole discretion,
immediately thereafter terminate this Agreement upon notice to CDO
without any further opportunity to cure or propose cure,
c. Consequences of Termination or Nonrenewal. If this Agreement is not renewed
pursuant to Section IV.b or is terminated pursuant to Sections V.a or V.b of this
Agreement, CDO's designation is automatically withdrawn. If that occurs CDO
must immediately cease holding out as a CDO to any Consumer, Applicant,
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Qualified individual, Enrollee, Qualified Employee, and Qualified Employer,
and/or these individuals' legal representative(s) or Authorized Representative(s),
must immediately cease providing CAC services to the public through its staff
members and volunteers, and must carry out procedures described in IL10.
VI. DESTRUCTION OF PII. CDO covenants and agrees to destroy all PIT in its possession
at the end of the record retention period required under Appendix A. If, upon the
termination or expiration of this Agreement, CDO has in its possession PIT for which no
retention period is specified in Appendix A. such PII shall be destroyed within 30 Days
of the teindnation or expiration of this Agreement. CDO's duty to protect and maintain
the privacy and security of PlI, as provided for in Appendix A of this Agreement, shall
continue in full force and effect until such Pll is destroyed and shall survive the
termination or expiration of this Agreement.
VII. MISCELLANEOUS
a. 'Notice. All notices specifically required under this Agreement shall be given in
writing and shall be delivered as follows:
if to CMS:
Centers for Medicare & Medicaid Services (CMS) •
Center for Consumer information Sz. Insurance Oversight (CCI10)
Attn: Office of the Director
Room 739H
200 Independence Avenue, SW
Washington, DC 20201
If to CDO, to CDO's address on record.
Notices sent by hand or overnight courier set-vice, or mailed by certified or
registered mail, shall be deemed to have beeii given when received; notices sent
by facsimile shall be deemed to have been given when the appropriate
confirmation of receipt has-been received; provided, that notices not given on a
business day (i.e., Monday - Friday excluding Federal holidays) between 9:00
a.m. and 5:00 p.m. local time where the recipient is located shall be deemed to
have been given at 9:00 a.m. on the next business day for the recipient. CMS and
CDO may Change their contact information, for notices and other communications
by providing thirty (30) Days' written notice of such change in accordance with
this provision.
b. Assignment and Subcontracting. CDO shall not assign this Agreement in whole
or in part, whether by merger,. acquisition, consolidation, reorganization or
otherwise, nor subcontract any portion of the services to be provided by CDO
under this Agreement, nor otherwise delegate any of its obligations under this
Agreement, without the express, prior written consent of CMS, which consent
may be withheld, conditioned, granted or denied in CMS's sole and absolute.
discretion. CDO further shall not assign this Agreement or any of its rights or
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obligations hereunder without the prior written consent of the State. If CDO
attempts to make an assignment, subcontract its service obligations or otherwise
delegate its obligations hereunder in. violation of this provision, such assignment,
subcontract or delegation shall be deemed void ab initio and of no force or effect,
and CDO shall remain legally bound hereto and responsible for all obligations
under this Agreement. CDO shall further be thereafter subject to such compliance
actions as may otherwise be provided for under applicable law.
c. Severability. The invalidity or unenforceability of any provision of this
Agreement shall not affect the validity or enforceability of any other provision of
this Agreement. In the event that any provision of this Agreement is determined
to be invalid, unenforceable or otherwise illegal, such provision shall be deemed
restated, in accordance with applicable law, to reflect as nearly as possible the
original intention of the parties, and the remainder of the Agreement shall be in
full force and. effect.
d. Disclaimer of Joint Venture. Neither this Agreement nor the activities of CDO
contemplated by and under this Agreement shall be deemed or construed to create
in any way any partnership, joint venture or agency relationship between CMS
and CDO. Neither CMS or CDO is, nor shall either CMS or CDO hold itself out
to be, vested with any power or right to bind the other contractually or to act on
behalf of the other, except to the extent expressly set forth in ACA and the
regulations codified thereunder, including as codified at 45 CFR part 155.
e. Remedies Cumulative. No remedy herein conferred upon or reserved to CMS
under this Agreement is intended to be exclusive of any other remedy or remedies
available to CMS under operative law and regulation, and each and every such
remedy, to the extent permitted by law, shall be cumulative and in addition to any
other remedy now or hereafter existing at law or in equity or otherwise.
Compliance with Law. CDO covenants and agrees to comply with any and all
applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable
to the conduct of the activities that are the subject of this Agreement, including
but not necessarily limited to, any additional and applicable standards required by
statute, and any regulations or policies implementing or interpreting such
statutory provisions hereafter issued by CMS. In the event of a conflict between
the term.s of this Agreement and, any statutory, regulatory, or sub-regulatory
guidance released by CMS, the .requirement which constitutes the stricter, higher
or more stringent level of compliance shall control.
g. Governing Law. This Agreement shall be governed by the laws and common law
of the United States of America, including without limitation such regulations as
may be promulgated from time to time by the •.11-1S or any of its constituent
agencies, without regard to any conflict of laws statutes or rules. CDO further
agrees and consents to the jurisdiction of the Federal Courts located within the
Page 13 of 16

District of Columbia and the courts of appeal therefrom, and waives any claim of
lack of jurisdiction or forum non conveniens.
h. Amendment. CMS may amend this Agreement for purposes of reflecting changes
in applicable law, regulations, or CMS implementation guidance, with such
amendments taking effect upon thirty (30) Days' written notice to CDO ("CMS
notice period"). Any amendments made under this provision will only have
prospective effect and will not be applied retrospectively. CDO may reject such
amendment, by providing to CMS, during the CMS notice period, thirty (30)
Days' written notice of its intent to reject the amendment ("rejection notice
period"). Any such rejection of an amendment made by CMS shall result in the
termination of this Agreement upon expiration of the rejection notice period.
1. Audit. CDO agrees that CMS, the Office of the Inspector General of HHS, and
the Comptroller General, as applicable, or their designees have the right to audit,
inspect, evaluate, examine, and make excerpts, transcripts, and copies of any
books, records, documents, and other evidence of CDO compliance with the
requirements of this Agreement, upon reasonable notice to CDO and during
CDO's regular business hours and at CDO's regular business location. CDO
further agrees to allow reasonable access to the information and facilities
requested by CMS, the Office of the Inspector General of HHS, and the
Comptroller General, as applicable, or their designees for the purpose of such an
audit.
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
Page 14 of 1.6

This Agreement between CDO and the Centers for Medicare & Medicaid Services for the
Federally-facilitated Exchange has been signed by:
FOR CDO
The undersigned is an official of CDO who is authorized to represent and bind CDO for
purposes of this Agreement.
Name and Title of Senior Official of CDO Date
CDO Name
CDO Designated ID Number
CDO Address
Page 15 of 16

FOR CMS
The undersigned are officials of CMS who are authorized to represent CMS for purposes
of this Agreement
James Kerr Date
Acting Deputy Director, Operations
Center for Consumer Information Sr, Insurance Oversight
Centers for Medicare & Medicaid Services
Tony Trerikle Date
Director and CMS 'Chief Information Officer
Office of Information Services •
Centers for Medicare & Medicaid Services
Robert Tagalicoel Date
Director
Office of E-Health Standards and Services
Centers for Medicare & Medicaid Services
Page 16 of •6

IN WITNESS WHEREOF, the parties agree to enter into this Agreement:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Deputy Attorney for Ma ricopa County
Date

APPENDIX A
PRIVACY AND.. SECURITY STANDARDS
AND
IMPLEMENTATION SPECIFICATIONS FOR NON-EXCHANGE.ENTIT S
Statement of Applicability:
These standards and implementation specifications are established in accordance with Section
1411(g) of the Affordable Care Act (42 U.S.C. § 18081(g)) and 45 CFR 155.260. As used in this
document, all terms used herein carry the meanings assigned in Appendix B, attached to this
Agreement.
The standards and implementation specifications that are set forth in this Appendix A and
Version 1.0 of the Minimum Acceptable Risk Standards—Exchanges (MARS-E) suite of
documents (which can be found at http://www.cms.gov/CCI10/Resources/Regulations-and-
Guidance!) are the same as, or more stringent than, the privacy and security standards and
implementation specifications that the Centers for Medicare and Medicaid Services ("CMS") has
established for the Federally-Facilitated Exchanges ("FFEs") established under Section 1321(c)
of the Affordable Care Act (42 U.S.C, § 18041(c)).
CMS will enter into contractual agreements with Non-Exchange Entities that gain access to
Personally Identifiable Information ("PII") exchanged with the FFEs, or directly from
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or these individuals' legal representative(s) or Authorized Representative(s).
Each such agreement and its appendices, which include this Appendix A, govern any Pll that is
created, collected, disclosed, accessed, maintained, stored, or used by the Non-Exchange Entity
in the context of the FFE. In signing any such contractual agreement, in which this Appendix A
has been incorporated, a Non-Exchange Entity agrees to comply with the standards and
implementation specifications laid out in this document and the referenced MARS-E suite of
documents while performing the Authorized Functions outlined in the agreement.

NON-EXCHANGE ENTITY PRIVACY AND SECURITY STANDARDS AND
IMPLEMENTATION SPECIFICATIONS
In addition to the standards and implementation specifications set forth in the MARS-E suite of
documents noted above, Non-Exchange Entities must meet the following privacy and security
standards and. implementation specifications to the extent they are not inconsistent with any
applicable MARS-E standards.
'.(1.) Individual Access to PH: In keeping with the standards and implementation
specifications used by the FFE, Non-Exchange Entities that maintain and/or store PH
must provide Consumers, Applicants, Oualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers, and/or these individuals legal representative()
and Authorized .Representative(s), with a simple and timely means of appropriately
accessing PH pertaining to them and/or the person they represent in a physical or
electronic readable form and _format
a. Standard: Non-Exchange Entities that maintain and/or store PII must implement
policies and procedures that provide access to PH upon request.
i. Implementation Specifications:
I. Access rights must apply to any PII that. is created collected,
disclosed, accessed, maintained, stored, and used by the Non-
Exchange Entity to perform any of the Authorized Functions
outlined in their respective agreements with the 'FFE.
The release of electronic documents containing PII through any
electronic means of communication (e.g., e-mail, web portal) must
meet the verification requirements for the release of "written
documents" in Section (5)b below.
3. Persons legally authorized to act on behalf of the Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees,
and Qualified Employers regarding their PI1, 'including individuals
acting under an appropriate power of attorney that complies with
applicable state and federal law, must be granted access in
accordance with their legal authority. Such access would generally
be expected to he coextensive with the degree of access available
to the Subject Individual,
4. At the time the request is made, the Consumer, Applicant,
Qualified Individual, Enrollee, Qualified Employees, Qualified
Employers and/or these individuals' legal representative(s) or
Authorized Representative(s) should generally be required to
specify which P1.1 he or she would like access to. The Non-
2

Exchange Entity may assist them in determining their Information
or data needs if such assistance is requested.
Subject to paragraphs (1 )a.i.6 and 7 below, Non-Exchange Entities
generally must provide access to the PH in the form or format
requested, if it is readily producible. in such form or format.
6. Unless the Non-Exchange Entity is a Certified Application
Counselor Designated Organization or Certified Application
Counselor, it may charge a fee only to recoup its costs for labor for
copying the PIT, supplies for creating a paper copy or a copy on
electronic media, postage if the PH is mailed, or any costs for
preparing an explanation or summary of the PI1 if the recipients
has requested and/or agreed to receive such summary. If such fees
are paid, the Non-Exchange Entity must provide the requested
copies in accordance with any other applicable standards and
implementation specifications. Under no circumstances may
Certified. Application Counselor Designated Organizations or
Certified Application Counselors charge any consumers any fees
for application or other assistance related to the Exchange
7. A Non-Exchange Entity that receives a request for notification of,
or access to PII must verify the requestor's identity in accordance
with Section (5)b
8. A Non-Exchange Entity must complete its review of a request for
access or notification (and grant or deny said notification and/or
access) within 30 Days of receipt of the notification and/or access
request.
9. Except as otherwise provided in (1)a.i..1 0, if the requested PH
cannot be produced, the Non-Exchange. Entity must provide an
explanation for its denial of the notification or access request, and,
if applicable, information regarding the availability of any appeal
procedures, including the appropriate appeal authority's name,
title, and contact information.
Unreviewable grounds for denial. Non-Exchange Entities may
deny access to PII that they maintain or store without providing an
opportunity for review, in the following circumstances:
a. If the PIT was obtained or created. solely for use in legal
proceedings;
b. If the PI1 is contained in records that are subject to a law
that either permits withholding the PII or bars the release of
such PH.

(2) Onenness and Transparency. In keeping with the standards and implementation
specifications used by the FEE, Non-Exchange Entities must ensure openness and
transparency about policies, procedures, and technologies that directly affect
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employers, and
Qualified Employees, and/or these individuals legal representative(s) or Authorized
Representative(s), and their PH
a. Standard: Privacy Notice Statement. Prior to collecting PH, the Non-Exchange
Entity must provide a notice that is prominently and conspicuously displayed on a
public facing Web site, if applicable, or on the electronic and/or paper form the
Non-Exchange Entity will use to gather and/or request PH.
i. Implementation Specifications.
1. The statement must be written in plain language and provided in a
manner that is accessible and timely to people living with
disabilities and with limited. English proficiency.
2. The statement must contain at a minimum the following
information:
a. Legal authority to collect PH;
b. Purpose of the information collection;
c. To whom PII mightbe disclosed, and for what purposes;
d. Authorized uses and disclosures of any collected
information;
e. Whether the request to collect PH is voluntary or
mandatory under the applicable law;
f. Effects of non-disclosure if an individual chooses not to
provide the requested information.
3, The Non-Exchange Entity shall maintain its Privacy Notice
Statement content by reviewing and revising as necessary on an
annual basis, at a minimum, and before or as soon as possible after
any change to its privacy policies and procedures.
4. If the Non-Exchange Entity operates a Web site, it shall ensure that
descriptions of its privacy and security practices, and information
on how to file complaints with CMS and the Non-Exchange Entity,
are publicly available through its Web site.
(3) Individual choice. in keeping with the standards and implementation specifications used
by the PEE, Non-Exchange Entities should ensure that Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, or these
individuals' legal representative(s) or Authorized Representative(s), are provided a
reasonable opportunity and capability to make informed decisions about the creation,
collection, disclosure, access, maintenance, storage, and use of their PII.
4

a, Standard: Informed Consent The Non-Exchange Entity may create, collect,
disclose, access, maintain, store, and use PII from Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, Qualified Employers or
these individuals' legal representative(s) or Authorized Representative(s), only for
the functions and purposes listed in the Privacy Notice Statem..ent and any relevant
agreements in effect as of the time the information is collected, unless the FEE or
Non-Exchange Entity obtains informed consent from such individuals.
i. Implementation specifications:
I The Non-Exchange Entity must obtain informed consent from
individuals for any use or disclosure of information that is not
permissible within the scope of the Privacy Notice Statement and
any relevant agreements that were in effect as of the time the P1I
was collected. Such consent must be subject to a right of
revocation.
Any such consent that serves as the basis of a use or disclosure
must:
a. Be provided in specific terms and in plain language;
b. Identify the entity collecting or using the PII, and/or
making the disclosure;
e, Identify the specific collections, use(s), and disclosure(s) of
specified PII with respect to a specific recipient(s);
d. Provide notice of an individual's ability to revoke the
consent at any time.
3. Consent documents must be appropriately secured and retained for
10 years.
(4) -Creation. collection, .dischnur.e, access, maintenance, storage, and use -limitatims. In
keeping with the standards and implementation specifications used by the FFE, Plon-
Exchange Entities must ensure that PII is only created, collected; disclosed, accessed,
maintained, stored, and used, to the extent necessary to accomplish a specified
purpose(s) in the contractual agreement and any appendices. Such information shall
never be used to discriminate against a Consumer, Applicant Qualified Individual,
Enrollee, Qualified Employee, Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s).
a. Standard: Other than in accordance with the consent procedures outlined above,
the Non-Exchange Entity shall only create, collect disclose, access, maintain,
store, and use P11:
1. To the extent necessary to ensure the efficient operation of the
Exchange;

2. In accordance with its published Privacy Notice Statement and any
applicable agreements that were in effect at the time the PU was
collected, including the consent procedures outlined above in
Section (3) above; and/or
3. In accordance with the permissible functions outlined in the
regulations and agreements between CMS and the Non-Exchange
Entity.
b. Standard: Non-discrimination. The Non-Exchange Entity should, to the greatest
extent practicable, collect PII directly from the Consumer, Applicant, Qualified
Individual, Enrollee, Qualified. Employee, or Qualified Employer when the
information may result in adverse determinations about beriefits,
c. Standard: Prohibited us and disclosures ofPII
1. Imolementation Specifications:
I. The Non-Exchange Entity shall not request information regarding
citizenship, status as a. national, or immigration status for an
individual who is not seeking coverage for himself or herself on
any application.
2. The Non-Exchange Entity shall not require an individual who is
not seeking coverage for himself or herself to provide a social
security number (SSN), except if an Applicant's eligibility is
reliant on a tax filer's tax return and their SSN is relevant to
verification of household income and family size.
3. The Non-Exchange Entity shall not use PIT to discriminate,
including employing marketing practices or benefit designs that
will have the effect of discouraging the enrollment of individuals
with significant health needs in Qualified Health Plans ("QHPs").
(5) Data quality and intearitv. In keeping with the standards and implementation.
specifications used by the FEE, Non-Exchange Entities should take reasonable. steps to
ensure that Pills complete, accurate, and up-to-date to the extent such data is necessary
for the Non-Exchange Entity's intended use of such data, and that such data has not been
altered or destroyed in an unauthorized manner, thereby ensuring the confidentiality,
integriiy, and availability of Pll.
a, Standard: Right to Amend. Correct, Substitute. or Delete NI., In keeping with the
standards and implementation specifications used by the FEE, Non-Exchange
Entities must offer Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, or these individuals' legal
6

representative(s) or Authorized Representative(s), an opportunity to request
amendment, correction, substitution, or deletion of PII maintained and/or stored
by the Non-Exchange Entity if such individual believes that the P11 is not
accurate, timely, complete, relevant, or necessary to accomplish an Exchange-
related function, except where the Information questioned originated from other
sources, in which case the individual should contact the originating source.
i. Implementation Specifications:
I. Such individuals shall he provided with 'instructions as to how they
should address their requests to the Non-Exchange Entity's
Responsible Official, in writing or telephonically. They may also
be offered an opportunity to meet with such individual or their
delegate(s) in person.
2. Such individuals shall be instructed to specify the following in
each request:
a. The Pil they wish to correct, amend, substitute or delete;
h. The reasons for requesting such correction, amendment,
substitution, or deletion, along with any supporting
justification or evidence.
3. Such requests must be granted or denied within no more than 10
working days of receipt.
4. If the Responsible Official (or their delegate) reviews these
materials and ultimately agrees that the identified PII is not
accurate, timely, complete, relevant or necessary to accomplish the
function for which the PH was obtained/provided, the PI.1 should
he corrected, amended, substituted, or deleted in accordance with
applicable law.
5. If the Responsible Official (or their delegate) reviews these
materials and ultimately does not agree that the P.11 should be
corrected, amended, substituted, or deleted, the requestor shall be
informed in writing of the denial, and, if applicable, the availability
of any appeal procedures. If available, the notification must
identify the appropriate appeal authority including that authority's
name, title, and contact information,
b. Standard: Verification of Identity for Reunc:;ts to Amend. Correct. Substitute or
Delete PIE In keeping with the standards and implementation specifications used
by the FEE, Non-Exchange Entities that maintain and/or store PII must develop
and implement policies and procedures to verify the identity of any person who
requests access to; notification of; or amendment, correction, substitution, or
deletion of PH that is maintained by or for the Non-Exchange Entity. This
7

includes confirmation of an individuals' legal or personal authority to access;
receive notification of; or seek amendment, correction, substitution, or deletion of
a Consumer's, Applicant's, Qualified Individuals', Enrollee's, Qualified
Employee's, or Qualified Employer's PH.
i. Implementation Specifications:
I. The requester must submit through mail, via an electronic upload
process, or in-person to the Non-Exchange Entity's Responsible
Official, a copy of one of the following government-issued
identification: a driver's license, school, identification card, voter
registration card, U.S. military card or draft record, identification
card issued by the .federal, state or local government, including a
U.S. passport, military dependent's identification card, Native
American tribal document, or U.S. Coast Guard Merchant Mariner
card.
2. If such requester cannot provide a copy of one of these documents,
he or she can submit two of the following documents that
corroborate one another: a birth certificate, Social Security card,
marriage Certificate, divorce decree, employer identification card,
high school or college diploma, _and/or property deed or title.
c. Standard: ,%.(.. , :.ountinfa for Disclosures. Except for those disclosures made to the
Non-Exchange Entity's Workforce who have a need for the record in the
performance of their duties; and the disclosures that are necessary to carry out the
required functions of the Non-Exchange Entity, Non-Exchange Entities that
maintain and/or store PH shall maintain an accounting of any and all disclosures.
i. Implementation Specifications:
1. The accounting shall contain the date, nature, and purpose of such
disclosures, and the name and address of the person or agency to
whom the disclosure is made
2. The accounting shall be retained for at least 10 years after the
disclosure, or the life of the record, whichever is longer.
3. Notwithstanding exceptions in Section (1)a.10, this accounting
shall be available to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, Qualified Employers, and/Or these
individuals' legal representative(s) or Authorized
Representative(s), on their request per the procedures outlined
under the access standards in Section (1) above.
8

(6) Accountability. In keeping with the standards and implementation specifications used by
the FEE, Non-Exchange Entities should adopt and implement the standards and
implementation specifications in this document and the cited lvfARS-E document suite, in
a manner that ensures appropriate monitoring and other means and methods to identifY
and report Incidents and/or Breaches,
a. Standard: Reporting, The Non.-Ex.change Entity must implement Breach and
Incident handling procedures that are consistent with CMS' Incident and Breach
Notification Procedures 1 and memorialized in the Non-Exchange Entity's own
written policies and procedures. Such policies and procedures would:
i.. Identify the Non-Exchange Entity's Designated Privacy Official, if
and/or identify other personnel authorized to access PH and
responsible for reporting and managing Incidents or Breaches to CMS.
ii. Provide details regarding the identification, response, recovery, and
follow-up of Incidents and Breaches, which should include information
regarding the potential need for CMS to immediately suspend or revoke
access to the Hub for containment purposes; and
Require reporting any Incident or Breach of Pll to the CMS IT Service
Desk by telephone at (410) 786-2580 or 1-800-562-1963 or via email
notification at cinsjtjervice desk@cms.hhs.gov within required time
frames.
b, Standard: Standard. OnLrafinu Procedures, The Non-Exchange Entity shall
incorporate privacy and security standards and implementation specifications,
where aPpropriate, in its standard operating procedures that are associated with
functions involving the creation, collection, disclosure, access, maintenance,
storage, or use of PIT
Implementation Specifications:
1. The privacy and security standards and. implementation
specifications shall be written in plain language and shall be
available to all of the Non-Exchange Entity's Workforce members
whose responsibilities entail the creation, collection, maintenance,
storage, access, or use of PIT.
2. The procedures shall ensure the Non-Exchange Entity's
cooperation with CMS in resolving any Incident or Breach,
including (if requested by CMS) the return or destruction of any
PI1 files it received under the Agreement; the provision of a formal
respon.seto an allegation of unauthorized PH use, reuse or
1 Available at htip://wwvv.cms.gov/Research-Statistics-Data-and-Systems/CMS-information-
Technology/InformationSecurity/Downloads/RMH VIII_I-lincidentilandling_Standard.pdf
9

disclosure; and/or the submission of a corrective action. plan with
steps designed to prevent any future unauthorized uses, reuses or
disclosures.
3. The standard operating procedures must be designed and
implemented to ensure the Non-Exchange Entity and its Workforce
comply with the standards and implementation specifications
contained herein, and must be reasonably designed, taking into
account the size and the type of activities that relate to PH
undertaken by the Non-Exchange Entity, to ensure such
compliance.
a. Standard: Training and Awareness. The Non-Exchange Entity shall develop
training and awareness programs for members of its Workforce that create,
collect, disclose, access, maintain, store, and use P11 while carrying out any
Authorized Functions.
Implementation Specifications:
1. The Non-Exchange Entity must require such individuals to
successfully complete privacy and security training, as appropriate
for their work duties and level of exposure to PII, prior to when
they assume responsibility for/have access to PIT.
2.- The Non-Exchange Entity must require periodic role-based
training on an annual basis, at a minimum..
3. The successful completion by such individuals of applicable
training programs, curricula, and examinations offered through the
FFE is sufficient to satisfy the requirements of this paragraph.
b. Standard: Security Controls. The FEE shall adopt and. implement the Security
Control standards cited in the MARS-E document suite for protecting the
confidentiality, integrity, and availability of PIE
i. Implementation Specifications:
1. Implementation specifications for each Security Control are
provided in the MARS-E document suite.
10

APPENDIX B
DEFINITIONS
This Appendix defines terms that are used in the Agreement and other Appendices. Any
capitalized term used in the Agreement that is not defined here has the meaning provided in 45
CPR 155.20.
(I) Affordable Care Act (ACA) means the Patient Protection and Affordable Care Act of
2010 (Public Law 111-148), as amended by the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), which are referred to collectively as
the Affordable Care Act.
(2) Access means availability of a SORN Record to a subject individual.
(3) Advance Payments of the Premium Tax Credit (APTC) has the meaning set forth in
45 CFR 155.20.
(4) Applicant has the meaning set forth in 45 CPR 155.20.
(5) Authorized Function means a task performed by a Non-Exchange Entity that the Non-
Exchange Entity is explicitly authorized or required to perform based on applicable law
or regulation, and as enumerated in the Agreement that incorporates this Appendix B.
(6) Authorized Representative means a person or.organization meeting the requirements set
forth in 45 CFR 155.227.
(7) Breach is defined by OMB- M:einorandum M-07-16, Safeguarding and Responding to the
Breach of Personally Identifiable Information (May "22, 2007), as the compromise,
unauthorized disclosure, unauthorized acquisition, unauthorized access, loss of control or
any similar term or phrase that refers to situations where persons other than authorized
users or for an other than authorized purpose have, access or potential access to Personally
Identifiable Information (PII), whether physical or electronic.
(8) CAC Certificate means the certificate issued to each CAC by his or her CDO, indicating
that b.e or she has been certified as a CAC, and containing the CAC's name and unique
CA.0 identification number.
(9) CCII0 means the Center for Consumer Information and Insurance Oversight within the
Centers for Medicare & Medicaid Services (CMS).
1

(10) Certified Application Counselor (CAC) means a staff member or volunteer who is
certified by a Certified Application Counselor Designated Organization to perform the
duties and meet the standards and requirements for CACs in 45 CFR 155.225,
Certified Application Counselor Designated Organization (CDO) means an
organization designated by the Federally-facilitated. Exchange to certify its staff members
or volunteers to act as CACs,
(12) CMS means the Centers for Medicare & Medicaid Services.
(1.3) CMS Data Services flub (Hub) is the CMS Federally-managed service to interface data
among connecting entities, including HEIS, certain other Federal agencies, and State
Medicaid agencies,
(14) Consumer means a person who, for himself or herself, or on behalf of another
individual, seeks information related to eligibility or coverage through a Qualified Health
Plan (QHP) or other insurance Affordability Program, or whom an agent or broker
(including Web-brokers), Navigator, Issuer, Certified Application Counselor, or other
entity assists in applying for a coverage through QHP, applying for Advance Payments of
the Premium Tax Credits (APTCs) an.d. Cost-sharing Reductions (CSRs), and/or
completing enrollment in a QHP through its web site for individual market coverage.
(15) Cost-sharing Reduction (CSR) has the meaning set forth in 45 CFR 155.20.
(16) Day or Days means calendar days unless otherwise expressly indicated in the relevant
provision of the Agreement that incorporates this Appendix B.
(17) Designated Privacy Official means a contact person or office responsible for receiving
complaints related to .Breaches or Incidents, able to provide further information about
matters covered by the notice, responsible for the development and implementation of the
privacy and security policies and procedures of the Non- .Exchange Entity, and ensuring
the Non-Exchange Entity has in place appropriate safeguards to protect the privacy and
security of PIT.
(1g) Enrollee has the meaning set forth in 45 CFR 155.20.
(19) Exchange has the meaning set forth in 45 CFR 155.20.
(20) Federally-facilitated Exchange (FFE) means an Exchange (or Marketplace)
established by HHS and operated by CMS under Section 1321(c)(1) of the ACA for
individual or small group market coverage, including the Federally-facilitated Small
Business Health Options Program (FF-SHOP). Federally-facilitated Marketplace
(FFM) has the same meaning as FFE,
2

(21) ITHS means the U.S. Department of Health & Human Services.
(22) Incident, or Security Incident, means the act of violating an explicit or implied security
policy, which includes attempts (either failed or successful) to gain unauthorized access
to a system or its data, unwanted disruption or denial of service, the unauthorized use of a
system for the processing or storage of data; and changes to system. hardware, firmware,
or software characteristics without the oNkater's knowledge, instruction, or consent.
(23) Information means any communication or representation of knowledge such as facts,
data, or opinions in any medium or form, including textual, numerical, graphic,
cartographic, narrative, or audioVisual.
(24) Insurance Affordability Program means a program that is one of the following:
(1) A State Medicaid program under title XIX of the Social Security Act.
(2) A State children's health insurance program (CHIP) under title XXI. of the Social
Security Act.
(3) A State basic health program established under section 1331 of the Affordable
Care Act.
(4) A program that makes coverage in a Qualified Health Plan through the Exchange
with Advance Payments of the Premium Tax Credit established under section 36B of
the Internal Revenue Code available to Qualified individuals.
(5) A program that makes available coverage in a .Qualified Health Plan through the
Exchange with Cost-sharing Reductions established under section 1402 of the
Affordable Care Act.
(25) Minimum Acceptable Risk Standards —Exchanges (MARS -E) means a CMS-
published suite of documents, version 1.0 (August 1, 2012), that defines the security
standards requited pursuant to 45 CFR 155.260 and 45 CFR 155.270, for any Exchange,
individual, or entity gaining access to information submitted to an Exchange or through
an Exchange using a direct, system-to-system connection to the Hub, available on the
CC110 web site.
(26) Navigator has the meaning set forth in 45 CFR 155.20.
(27) Non -Exchange Entity has the meaning at 45 CFR. 155.260(b), including hut not limited
to Navigators, agents, and brokers.
(28) OMB means the Office of Management and Budget.
3

(29) Personally identifiable Information (P11) has the meaning contained in OMB
Memoranda M-07 7 16 (May 22, 2007) and means information which can be used to
distinguish or trace an individual's identity, such as their name, social security number,
biometric records, etc., alone, or when combined with other personal or identifying
information that is linked or linkable to a specific individual, such as date and place of
birth, mother's maiden name, etc.
(30) Qualified Employee has the meaning set forth in 45 CFR 155.20.
(31) Qualified Employer has the meaning set forth in 45 CFR 155.20.
(32) Qualified Health Plan (QHP) has the meaning set forth in 45 CFR 155.20.
(33) Qualified Individual has the meaning set forth in 45 CFR 155.20.
(34) Responsible Official means an individual or officer responsible for managing a Non
Exchange Entity or Exchange's records or information systems, oranother individual
designated as an individual to whom requests can be made, or the designee of either such
officer or individual who is listed in a Federal System of Records Notice as the system
manager, or another individual listed as an individual to whom requests may be made, or
the designee of either such officer or individual.
(35) Security Control means a safeguard or countermeasure prescribed for an information
system or an organization designed toprotect .the confidentiality, integrity, and
availability of its information and to meet a set of defined security requirements.
(36) State means the State where the Certified Application Counselor that is a party to this
Agreement is operating.
(37) State Partnership Exchange means a type of FFE in which a State assumes
responsibility for carrying out certain activities related to plan management, consumer
assistance, or both.
(38) Subject Individual means that individual to whom a SORN Record pertains.
(39) System of Records means a group of Records under the control of any Federal agency
from which information is retrieved by name of the individual or by some identifying
number, symbol, or other identifying particular assigned to the individual.
4

(40) System of Records Notice (SORN) means a notice published in the Federal Register
notifying the public of a System of Records maintained by a Federal agency. The notice
describes privacy considerations that have, been addressed in implementing the system.
(41) System of Record Notice (SORN) Record means any item, collection, or grouping of
information about an individual that is maintained by an agency, including but not limited
to that individual's education, financial transactions, medical history, and .criminal or
employment history and that contains that individual's name, or an identifying number,
symbol, or the identifying number, symbol, or other identifying particular assigned to the
individual, such as a finger or voice print or a photograph, that is part of a System of
Records.
(42) Training Certificate means the certificate issued to each potential CAC by the Medicare
Learning Network upon their completion of the required CMS-approved training courses
and examinations.
(43) Web means the World Wide Web.
(44) Workforce means a Non-Exchange Entity's or FFE's employees, agents, contractors,
subcontractors, officers, directors, agents, representatives, and any other individual who
may create, collect, disclose, access, maintain, store, or use PH in the performance of his
or her duties.
5

APPENDIX E
Model Authorization Form Template for Certified Application Counselor Designated
Organizations and Certified Application Counselors (CACs) in States with a Federally Facilitated
Marketplace (FFIVI) or State Partnership Marketplace (SPIVI)
CAC Designated Organization Name and Address:
CAC Designated Organization Phone Number and Email:
Individual CAC Name and Certification Number:
. give my permission, or. [Insert name of authorized
representative], my legal or Marketplace authorized representative acting on my behalf ("authorized
representative"), gives permission to [Insert CAC Designated Organization Name and Individual CAC
name here] to create, collect, disclose, access, maintain, use, and/or store my personally identifiable
information (P1I) and/or the PII of my authorized representative, to perform the following duties of a
CAC Designated Organization or CAC':
Inform me and/or my authorized, representative about the full range of Marketplace health
coverage options and insurance affordability programs for which I'm eligible;
▪ Help me complete my application for health coverage in a Qualified Health Plan (QHP) through
the Marketplace and for insurance affordability programs;
▪ Help me enroll in a Q.HP or in an insurance affordability program.
I understand that I may revoke this authorization at any time and will notify [insert CAC-designated
Organization Name and Individual CAC name here] if I choose to revoke my authorization.
I understand that [Insert CAC Designated Organization Name and Individual CAC name here] have the
following responsibilities and will perform the following functions:
`i,•-• [Insert CAC Designated Organization Name and Individual CAC name here] will•inform me
and/or my authorized representative about the full range of Marketplace health coverage options
and 'insurance affordability programs for which I'm eligible, will help me apply for health
coverage in a OHP through the Marketplace and for insurance affordability programs, and will
help me enroll in a QFIP or in an insurance affordability program.
▪ [Insert CAC Designated Organization Name and Individual CAC name here] will inform me of
any possible conflicts of interest they might have.
• [Insert CAC Designated Organization Name and Individual CAC name here] can't choose a
health insurance plan for me.
[Insert CAC Designated Organization Name and individual CAC name here] is required to act in
my best interest.
These duties are set forth in 45 CFR §155.225,

• [Insert CAC Designated Organization Name and Individual CAC name here] will follow privacy
and information security standards when creating, collecting, disclosing, accessing, maintaining,
storing, and/or using my PII and/or the Pll of my authorized representative. Information about
these standards will be provided.
• [insert CAC Designated Organization Name and Individual CAC name here] aren't expected or
required to maintain or store any of my PII and/or the PIE of my authorized representative, other
than this authorization form, but if [Insert CAC Designated Organization Namc and Individual
CAC name here] do maintain or store my PII, they will follow privacy and information security
standards.
• I and/or my authorized representative don't have to give [Insert CAC Designated Organization
Name and Individual CAC name here] more information than I and/or my authorized
representative choose to provide.
• The assistance [Insert CAC Designated Organization Name and Individual CAC name here]
provide is based only on the information I and/or my authorized representative provide, and if the
information provided is inaccurate or incomplete, [Insert CAC Designated Organization Name
and Individual CAC name here] may not be able toprovide all the assistance available for my
situation.
• If [Insert CAC .Designated Organization Name and individual CAC name here] are unable to
assist me and/or my authorized representative, they will refer me or my authorized representative
to another person who can help me (a Navigator or other Marketplace-authorized assistance
personnel), or to the Exchange call center.
.S? [Insert CAC Designated Organization Name and Individual CAC name here] won't charge me
and/or my authorized representative a fee for any assistance provided,
Please sign and datethe form:
Signature of Consumer/Consumer's Legal or Marketplace Authorized Representative (please circle a
status to indicate whether you're the consumer or the consumer's representative)
Date
PLEASE NOTE: Consumers may sign this authorization form themselves, or choose to have a legal or
Marketplace Authorized Representative complete this form.

MODEL AGREEMENT BETWEEN CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH THE FEDERALLY-
FACILITATED EXCHANGE IS OPERATING AND CERTIFIED APPLICATION
COUNSELOR
THIS AGREEMENT ("Agreement") is entered into between Maricopa County Department
of Public Health, Health Care for the Homeless, an organization that The Centers for
Medicare & Medicaid Services ("CMS"), which manages and oversees the Federally-facilitated
Exchanges ("FFEs"), has designated as a Certified Application Counselor Designated
Organization in Arizona. a State/States in which an FFE is operating (hereinafter referred to as
"CDO") and Eureka King, a staff member or volunteer of the CDO who wishes to be certified by
the CDO to act as a Certified Application Counselor (hereinafter referred to as "Staff
Member/Volunteer") and to perform the duties and meet the standards and requirements of 45
CFR 155.225. The CDO and Staff Member or Volunteer are hereinafter sometimes referred to
as "Party," or, collectively, as the "Parties."
WHEREAS:
• Pursuant to 45 CFR 155.225(b), CMS may designate an organization to certify its staff
members or volunteers to act as Certified Application Counselors.
2. CMS has designated CDO to certify staff members and volunteers to act as certified
application counselors in an FFE.
3. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QHP through the FFE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
4. The CDO, and the staff members and volunteers that the CDO certifies as CACs, will
need to create, collect, disclose, access, maintain, store, and/or use the Personally
Identifiable Information ("PII") from CMS, Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) that is necessary to carry out the
Authorized Functions described at III.b below.
5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and
1

Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s), in order to perform the Authorized Functions described in Section
Mb of this Agreement.
6. 45 CFR 155.225(d)(3) requires all CACs to comply with the Exchange's privacy and
security standards adopted consistent with 45 CFR 155.260, and applicable
authentication and data security standards.
7. CMS, in the administration of the FFEs, has .adopted privacy and security standards
concerning personally identifiable information ("PII") and applicable authentication and .
data security standards, which are set forth in Appendix A. "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities" Compliance
with this Agreement satisfies the requirement under 45 CFR 1.55.225(d)(3) to comply
with applicable authentication and data security standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
I. DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
II. OBLIGATIONS AND CONDITIONS
a. Staff Member/Volunteer's Oblig.ations and Conditions. To carry out the functions
authorized by 45 CFR 155.225, and as a condition of Staff Member/Volunteer's
certification by CDO, Staff Member/Volunteer agrees to the following:
• Prior to functioning as a CAC, Staff Member/Volunteer shall do all of the
following:
1. Register with CDO and receive a unique identifying number and a
CAC Certificate, in accordance with CDO's procedures [ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL BY REFERENCE RATHER
THAN CREATE ITS OWN PROCEDURES] as set forth in Section 2
of the CAC User Manual, which is incorporated by reference into this
Agreement Appendix C, "CAC User Mannar];
2. Register for CMS-approved training using Staff Member/Volunteer's
unique CAC identification number and the name that will appear on
both his or her CAC Certificate and Training Certificate;
3, Complete CMS-approved training regarding QHP options, Insurance
Affordability Programs, eligibility, and benefits rules and regulations
2

governing all Insurance Affordability Programs operated in the state,
as implemented in the state;
4. Complete and achieve a passing score on all CMS-approved
certification examinations;
5. Provide proof in the form of his or her printed Training Certificate to
CDO that he or she has fulfilled the training and certification
examination requirements specified in Section II.h.i.2 and 3; and
6. Execute this Agreement.
ii. Staff Member/Volunteer shall disclose to CDO and to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized
Representative(s) any relationship Staff Member/Volunteer has with QHPs or
Insurance Affordability Programs, or other potential conflicts of interest;
iii. [FOR USE ONLY IF THE CDO DECIDES TO REQUIRE THIS] Staff
Member/Volunteer shall disclose to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) any relationship
the CDO has with QIIPs or Insurance Affordability Programs, or other
potential conflicts of interest, using language supplied by CDO;
iv. Staff Member/Volunteer shall comply with all provisions of this Agreement
and its attachments, all of which are hereby incorporated by reference,
including Appendix A, "Privacy and Security Standards and implementation
Specifications for Non-Exchange Entities," which was drafted in conformance
with 45 CFR 155.260;
v. Staff Member/Volunteer shall act in the best interests of any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, or Qualified
Employer that he or she assists;
vi. Staff Member/Volunteer shall, either directly or through an appropriate
referral to a Navigator or non-Navigator assistance personnel authorized under
45 CFR §§ 155.205(d) and (e) or 155.210, or to the Exchange call center
authorized under 45 CFR § 155.205(a), provide information in a manner that
is accessible to individuals with disabilities, as defined by the Americans with
Disabilities Act, as amended, 42 USC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
vii. Staff Member/Volunteer shall provide infoilnation to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized

Representative(s) about the full range of QHP options and Insurance
Affordability Programs for which they are eligible;
viii. Staff Member/Volunteer shall assist Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) in applying for
coverage in a QHP through the Marketplace and for Insurance Affordability
Pro grains;
ix. Staff Member/Volunteer shall help to facilitate enrollment of eligible
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers in QHPs and Insurance Affordability
Programs;
x. Staff Member/ Volunteer shall follow CDO's established procedures[ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL AND SOPS BY REFERENCE RATHER
THAN DEVELOP OTHER PROCEDURES] as set forth in Appendix C,
"CAC User Manual," and Appendix D, "CAC Standard Operating Procedures
(SOPs)," which are incorporated by reference into this Agreement), to:
1. Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) the CAC
Certificate provided by CDO evidencing the individual's certification
as a CAC- each time Staff Member/Volunteer assists any of these
persons;
2. Infoun Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), of the functions and
responsibilities of CACs. Staff Member/Volunteer may use the model
form provided by CMS and appended hereto and referred to as
Appendix E to fulfill this requirement;
3. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PII of Consumers, Applicants, Qualified
Enrollees, Qualified Employees, Qualified Employers,
and/or these individual's legal representatives(s) or Authorized
Representative(s) obtain the authorization required by 45 CFR
I 55.225(f) and section III.d of this Agreement (hereinafter referred to
as "authorization") to create, collect, disclose, access, maintain, store,
and use PII of such person(s) to carry out the Authorized Functions
listed at Section III.b of this Agreement. This authorization may be
obtained either directly from the Consumer, Applicant, Qualified
Individual, Enrollee, Qualified Employee, and/or Qualified Employer,
4

or through such person(s)' legal representative(s) or Authorized
Representative(s). Staff Member/Volunteer may use the model form
provided by CMS and appended hereto and referred to as Appendix E
to fulfill this requirement. This authorization is separate and distinct
both from any authorization obtained pursuant to section III.g of this
agreement and from the informed consent referenced in Appendix A at
3(0;
4. Maintain a record of the authorization provided under Section II.a.x.3;
5. Perinit the Consumer, Applicant, Qualified Individual, Enrollee,
Qualified Employee, and Qualified Employer, and/or their legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section II.a.x.3. at any time;
6. Provide his or her unique CAC identification number to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) assisted by Staff
Member/Volunteer, and include his or her unique CAC identification
number on any application that is partially or fully completed in
connection with Staff Member/Volunteer's assistance for that
individual;
xi. Staff Member/ Volunteer shall not impose any charge on any Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s) for application or other assistance related to the Exchange;
xii. Staff Member/Volunteer shall not sell or otherwise transfer information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) to any person or entity
other than such actions as are specifically permitted by this Agreement;
xiii. Staff Member/Volunteer shall not collect or otherwise maintain information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), except as specifically
provided for in this Agreement;
xiv. Upon termination or nonrenewal of Staff Member/Volunteer's agreement with
CDO, Staff Member/Volunteer shall immediately cease holding himself or
herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these

individuals' legal representative(s) or Authorized Representative(s), and
immediately cease providing CAC services to the public; and
xv. As evidenced by my signature hereon, I hereby agree to provide the duties and
services described herein without compensation of any kind (other than the
wages I may nonetheless earn as an employee of CDO for work performed on
behalf of my employer), and hereby waive my rights to any fee, remuneration
or compensation to which I might somehow be entitled to receive from the
Government of the United States of America under applicable law.
III. OBLIGATIONS RELATED TO THE PRIVACY AND SECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION,
a. Staff Member/Volunteer hereby acknowledges and agrees to accept and abide by the
standards and implementation specifications set forth below and in Appendix A,
"Privacy and Security Standards and Implementation Specifications for Non-
Exchange Entities," which is incorporated by reference in this Agreement, when
engaging in any activity as a CAC pursuant to 45 CFR 155.225. Staff Member/
Volunteer is thereby bound to strictly adhere to the privacy and security standards,
and to ensure that any Workforce it may have that creates, collects, accesses, stores,
maintains, discloses, or uses PII, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the efficient
operation of the FFE.
b. Authorized Functions. Staff Member/ Volunteer may create, collect, disclose, access,
maintain, store, and use PII of Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, Or these individuals' legal
representative(s) or Authorized Representative(s), in order to:
1. Provide information about the fidl range of QHP options and Insurance
Affordability Programs for which these persons are eligible;
Assist these persons with applications for coverage in a QHP through the FTE and
for Insurance, Affordability Programs;
3. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
4. Perfolin other functions authorized under 45 CFR 155.225, including functions
substantially similar to those enumerated above, and such. other functions that
may be approved by CDO in writing from time to time, but only if CMS has
expressly permitted CDO to carry out those functions.
c. P11 Received, Subject to the terms and conditions of this Agreement and applicable
laws, in performing the tasks contemplated under this Agreement, Staff Member/
Volunteer may create, collect, disclose, access, maintain, store, and use the following
6

data and PII from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or these individuals' legal representative(s) Or
Authorized Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, start and end
dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amount
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birtbdate
Contact Telephone number
Contact Email
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FFE Applicant ID
FFE Member ID
"Issuer Member ID
Net premium amount
Pregnancy indicator
Premium Amount, start and end dates
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
7

d. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any P11 from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), Staff Member/Volunteer will
obtain the authorization required under Section II.a.x.3 of this Agreement to create,
collect, disclose, access, maintain, use, or store their PIT to carry out the Authorized
Functions listed at Section III.b of this Agreement, and will permit the authorization
to be revoked at any time. Staff Member/Volunteer may use the model form provided
by CMS and appended hereto and referred to as Appendix E to fulfill this
requirement. This authorization is separate and distinct from any authorization
obtained pursuant to section 111.g of this agreement and the informed consent
referenced in Appendix A at 3(a). The CDO should ensure that a record of the
authorization provided is maintained in a manner consistent with the privacy and
security standards set forth in Appendix A.
e. Collection of PII. PH collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), may be used only for the
Authorized Functions specified in Section III.b of this Agreement. Such information
may not be reused for any other purpose,
f. Storing, P11. Other than documentation related to the authorization required by Section
111.d above, Staff Member/Volunteer is not expected or required to maintain or store
any of the above listed PH as a result of carrying out the Authorized Functions
specified in Section III.b above. To the extent that Staff Member/Volunteer does
maintain or store PH, such as documentation related to the authorization required by
Section III.d, he or she must agree to comply with all provisions of this Agreement
and Appendix A that apply to the maintenance or storage of P11.
g. Collection and Use of Infoiniation Provided Under Other Authorities. This
Agreement does not preclude Staff Member/Volunteer from separately collecting
infoimation from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such
non-FFE information obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must be separately collected and stored from
any PII collected in accordance with this Agreement. Any authorization for collection
and use of PII under this provision is separate and distinct from the authorization
obtained pursuant to Section Ind above and II.a.x.3, and should be obtained and
maintained separately from that authorization.
h. Ability of Consumer to Limit Collection and Use. Staff Member/Volunteer agrees to
allow the Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
Qualified Employer, directly or through their legal representative(s) or Authorized
Representative(s), to limit Staff Member/Volunteer's creation, collection, use,
maintenance, storage, and disclosure of their PII to the sole purpose of obtaining Staff
8

Member/Volunteer's assistance for FFE purposes, and for perfoituing Authorized
Functions specified in Section III.b of this Agreement.
IV. EFFECTIVE DATE TERM AND RENEWAL.
a. Effective Date and T. This Agreement becomes effective on the date the last of
the two Parties signs this Agreement and ends one year from the effective date,
b. Renewal. This Agreement will automatically renew for subsequent and consecutive
one (1) year periods upon the expiration. of this Agreement, unless:
i. CDO is no longer designated by CMS; or
CDO, in its sole an.d absolute discretion, notifies Staff Member/Volunteer
with 30 Days' advance written notice.th.at it has deteimin.ed that the
Agreement will not be renewed. Such notice will specify whether and under
what. conditions CDO will renew the Agreement; or
CDO terminates the Agreement pursuant to Section V of this Agreement.
V. Termination
a. Terannation without Cause. Either Party may terminate this Agreement without
cause upon thirty (30) Days' prior written notice to the other Party.
b. Termination with Cause. This Agreement shall telininate immediately when Staff
Member/Volunteer no longer holds a position as a staff member or volunteer at CDO,
or when CDO withdraws Staff Member/Volunteer's certification as a CAC, or when
CMS has withdrawn CDO's designation as a CDO. CDO may terminate this
Agreement for cause as soon as possible, but in no event later than twenty (20) Days
after the triggering event (identification or notification of noncompliance) if CDO
learns or is notified by CMS that Staff Member/Volunteer has failed to comply with
the terms and conditions of this Agreement or with any applicable requirements of 45
CFR 155.225, unless Staff Member/Volunteer commences curing such breach(es)
within such 20-Day period to the reasonable satisfaction CDO, and thereafter
diligently implements such cure to completion. The 20-Day notice from CDO shall
contain a description of the material breach, whereupon Staff Member/Volunteer
shall have seven (7) Days from the date of the notice in which to propose a plan and a
time frame to cure the material breach, which plan and time frame may be rejected,
approved or amended in CDO's sole but reasonable discretion. Notwithstanding the
foregoing, Staff Member /Volunteer shall be considered in "Habitual Default" of this
Agreement in the event that it has been served with a 20-Day notice under this
subsection more than three (3) times in any calendar year, whereupon CDO may, in
its sole discretion, immediately thereafter terminate this Agreement upon notice to
Staff Member/Volunteer without any further opportunity to cure or propose cure.
c. Consequences of Termination or Nonrenewal. If this Am-cement is not renewed
pursuant to Section IV.b or is terminated pursuant to Sections V.a or V.b of this
9

Agreement, Staff Member/Volunteer's certification as a CAC is automatically
withdrawn. if that occurs Staff Member/Volunteer must immediately cease holding
himself or herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these individuals'
legal representative(s) or Authorized Representative(s), and must immediately cease
providing CAC services to the public.
VI. DESTRUCTION OF PII. Staff Member/Volunteer covenants and agrees to destroy all
PIT in his or her possession at the end of the record retention period required under
Appendix A. If, upon the termination or expiration of this Agreement Staff Member/
Volunteer has in his or her possession PI1 for which no retention period is specified in
Appendix A, such PIT shall be destroyed within thirty (30) Days of the teimination or
expiration of this Agreement. Staff Member/Volunteer's duty to protect and maintain the
privacy and security of PI1, as provided for in Appendix A of this Agreement, shall
continue in full force and effect until such PIT is destroyed and shall survive the
teimination or expiration of this Agreement.
VII. GENERAL PROVISIONS.
a. Assimment and Delegation. Staff Member/Volunteer shall not assign its rights or
delegate its performance under this Agreement. CDO shall not assign its rights or
delegate its performance under this Agreement without the express prior written
consent of CMS.
b. Disclaimer. Neither this Agreement nor the activities of the Parties contemplated
under this Agreement shall be deemed or construed to create in any way any
partnership, joint venture or agency relationship between either or both of the Parties
hereto on one hand and the United States of America (or any of its agencies or
departments) on the other. Neither CDO nor Staff Member/Volunteer is, nor shall
either CDO or Staff Member/Volunteer hold itself out to be, vested with any power,
authority or right to act on behalf of the United States of America in any manner as an
agent or representative thereof, or to bind the United States in any manner or fashion.
C. Amendments. CDO may amend this Agreement for purposes of reflecting changes in
applicable law, regulations, or CMS implementation guidance, with such amendments
taking effect upon thirty (30) Days' written notice to Staff Member/Volunteer ("CDO
notice period"). Staff Member/Volunteer may reject such amendment, by providing
to CDO, during the CDO notice period, thirty (30) Days' written notice of its intent to
reject the amendment ("rejection notice period"). Any such rejection of such
amendment made by CDO for purposes of reflecting changes in applicable law,
regulations, or CMS implementation guidance shall result in the termination of this
Agreement upon expiration of the rejection notice period.
10

d. Compliance with Law. CDO and Staff Member/Volunteer shall comply with any and
all applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable to
the conduct of the activities that are the subject of this Agreement, including but not
limited to, any additional and applicable standards required by statute, and any
regulations or policies implementing or interpreting such statutory provisions
hereafter issued by CMS. In the event of a conflict between the terms of this
Agreement and, any statutory, regulatory, or sub-regulatory guidance released by
CMS, the requirement which constitutes the stricter, higher or more stringent level of
compliance controls.
e. [Placeholder for Governing Law provision]
f. [Placeh.older for Notices provi sion
g. [Placebolder for Severability provision]
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]

This "Agreement between CDO and Staff Member/Volunteer has been signed by:
FOR CDO:
By:
[Title of person authorized to enter into
agreements on behalf of organization to bind
the organization]
Date:
FOR Staff Member/Volunteer:
Printed Name:
Eureka King
Date: 1T27
12

MODEL AGREEMENT BETWEEN CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH THE FEDERALLY-
FACILITATED EXCHANGE IS OPERATING AND CERTIFIED APPLICATION
COUNSELOR
THIS AGREEMENT ("Agreement") is entered into between Maricopa County Department
of Public Health, Health Care for the Homeless, an organization that The Centers for
Medicare & Medicaid Services ("CMS"), which manages and oversees the Federally-facilitated
Exchanges ("FFEs"), has designated as a Certified Application Counselor Designated
Organization in Arizona, a State/States in which an FFE is operating (hereinafter referred to as
"CO") and Beverly Leyvas, a staff member or volunteer of the CDO who wishes to be certified
by the CDO to act as a Certified Application Counselor (hereinafter referred to as "Staff
Member/Volunteer") and to perform the duties and meet the standards and requirements of 45
CFR 155.225. The CDO and Staff Member or Volunteer are hereinafter sometimes referred to
as "Party," or, collectively, as the "Parties."
WHEREAS:
1. Pursuant to 45 CFR 155.225(b), CMS may designate an organization to certify its staff
members or volunteers to act as Certified Application Counselors.
2. CMS has designated CDO to certify staff members and volunteers to act as certified
application counselors in an FFE.
3. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QHP through the FFE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
4. The CDO, and the staff members and volunteers that the CDO certifies as CACs, will
need to create, collect, disclose, access, maintain, store, and/or use the Personally
Identifiable Information ("PI1") from CMS, Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) that is necessary to carry out the
Authorized Functions described at III.b below.
5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and

Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s), in order to perform the Authorized Functions described in Section
III.b of this Agreement.
6. 45 CFR 155.225(4)(3) requires all CACs to comply with the Exchange's privacy and
security standards adopted consistent with 45 CFR 155.260, and applicable
authentication and data security standards.
7. CMS, in the administration of the FFEs, has adopted privacy and security standards
concerning personally identifiable information ("PIT") and applicable authentication and
data security standards, which are set forth in Appendix A, "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities." Compliance
with this Agreement satisfies the requirement under 45 CFR 155.225(d)(3) to comply
with applicable authentication and data security standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
I. DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
II. OBLIGATIONS AND CONDITIONS
a. Staff Member/Volunteer's Obligations and Conditions. To carry out the functions
authorized by 45 CFR 155.225, and as a condition of Staff Member/Volunteer's
certification by CDO, Staff Member/Volunteer agrees to the following:
• Prior to functioning as a CAC, Staff Member/Volunteer shall do all of the
following:
I. Register with CDO and receive a unique identifying number and a
CAC Certificate, in accordance with CDO's procedures [ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL BY REFERENCE RATHER
THAN CREATE ITS OWN PROCEDURES] as set forth in Section 2
of the CAC User Manual, which is incorporated by reference into this
Agreement Appendix C, "CAC User Manual"];
2. Register for CMS-approved training using Staff Member/Volunteer's
unique CAC identification number and the name that will appear on
both his or her CAC Certificate and Training Certificate;
3. Complete CMS-approved training regarding QHP options, Insurance
Affordability Programs, eligibility, and benefits rules and regulations
2

governing all Insurance Affordability Programs operated in the state,
as implemented in the state;
4. Complete and achieve a passing score on all CMS-approved
certification examinations;
5. Provide proof in the form of his or her printed Training Certificate to
CDO that he or she has fulfilled the training and certification
examination requirements specified in Section II.b,i.2 and 3; and
6. Execute this Agreement.
ii. Staff Member/Volunteer shall disclose to CDO and to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized
Representative(s) any relationship Staff Member/Volunteer has with QHPs or
Insurance Affordability Programs, or other potential conflicts of interest;
iii. [FOR USE ONLY IF THE CDO DECIDES TO REQUIRE THIS] Staff
Member/Volunteer shall disclose to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) OF Authorized Representative(s) any relationship
the CDO has with QHPs or Insurance Affordability Programs, or other
potential conflicts of interest, using language supplied by CDO;
iv. Staff Member/Volunteer shall comply with all provisions of this Agreement
and its attachments, all of which are hereby incorporated by reference,
including Appendix A, "Privacy and Security Standards and Implementation
Specifications for Non-Exchange Entities," which was drafted in conformance
with 45 CFR 155.260;
v. Staff Member/Volunteer shall act in the best interests of any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, or Qualified
Employer that he or she assists;
vi. Staff Member/Volunteer shall, either directly or through an appropriate
referral to a Navigator or non-Navigator assistance personnel authorized under
45 CFR §§ 155.205(d) and (e) or 155.210, or to the Exchange call center
authorized under 45 CFR § 155.205(a), provide infoimation in a manner that
is accessible to individuals with disabilities, as defined by the Americans with
Disabilities Act, as amended, 42 USC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
vii. Staff Member/Volunteer shall provide information to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized

Representative(s) about the full range of QI-IP options and Insurance
Affordability Programs for which they are eligible;
viii. Staff Member/Volunteer shall assist Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) in applying for
coverage in a QHP through the Marketplace and for Insurance Affordability
Programs;
ix. Staff Member/Volunteer shall help to facilitate enrollment of elio:ible
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers in QHPs and Insurance Affordability
Programs;
x. Staff Member/ Volunteer shall follow CDO's established procedures[ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL AND SOPS BY REFERENCE .RATHER
THAN DEVELOP OTHER PROCEDURES] as set forth in Appendix C,
"CAC User Manual," and Appendix D, "CAC Standard Operating Procedures
(SOPs)," which are incorporated by reference into this Agreement], to:
I. Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) the CAC
Certificate provided by CDO evidencing the individual's certification
as a CAC each time Staff Member/Volunteer assists any of these
persons;
2. Inform Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), of the functions and
responsibilities of CACs. Staff Member/Volunteer may use the model
form provided by CMS and appended hereto and referred to as
Appendix E to fulfill this requirement;
3. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PII of Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, Qualified Employers,
and/or these individual's legal representatives(s) or Authorized
Representative(s) obtain the authorization required by 45 CFR
155.225(f) and section III.d of this Agreement (hereinafter referred to
as "authorization") to create, collect, disclose, access, maintain, store,
and use PIT of such person(s) to carry out the Authorized Functions
listed at Section III.b of this Agreement. This authorization may be
obtained either directly from the Consumer, Applicant, Qualified
Individual, Enrollee, Qualified Employee, and/or Qualified Employer,

or through such person(s)' legal representative(s) or Authorized
Representative(s). Staff Member/Volunteer may use the model form
provided by CMS and appended hereto and referred to as Apnendix E
to fulfill this requirement. This authorization is separate and distinct
both. from any authorization obtained pursuant to section III.g of this
agreement and from the informed consent referenced in Appendix A at
3(a);
4. Maintain a record of the authorization provided under Section Il.a.x.3;
5. Peanit the Consumer, Applicant, Qualified Individual, Enrollee,
Qualified Employee, and Qualified Employer, and/or their legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section II.a.x.3. at any time;
6. Provide his or her unique CAC identification number to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) assisted by Staff
Member/Volunteer, and include his or her unique CAC identification
number on any application that is partially or fully completed in
connection with Staff Member/Volunteer's assistance for that
individual;
xi. Staff Member/Volunteer shall not impose any charge on any Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s) for application or other assistance related to the Exchange;
xii. Staff Member/Volunteer shall not sell or otherwise transfer infolination
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) to any person or entity
other than such actions as are specifically permitted by this Agreement;
xiii. Staff Member/Volunteer shall not collect or otherwise maintain information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), except as specifically
provided for in this Agreement;
xiv. Upon termination or nonrenewal of Staff Member/Volunteer's agreement with
CDO, Staff Member/Volunteer shall immediately cease holding himself or
herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these
5

individuals' legal representative(s) or Authorized Representative(s), and
immediately cease providing CAC services to the public; and
xv. A.s evidenced by my signature hereon, I hereby agree to provide the duties and
services described herein without compensation of any kind (other than the
wages I may nonetheless earn as an employee of CDO for work performed on
behalf of my employer), and hereby waive my rights to any fee, remuneration
or compensation to which I might somehow be entitled to receive from the
Government of the United States of America. under applicable law.
III. OBLIGATIONS RELATED TO THE PRIVACY AND SECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION.
a. Staff Member/Volunteer hereby acknowledges and agrees to accept and abide by the
standards and implementation specifications set forth below and in Appendix A,
"Privacy and Security Standards and Implementation Specifications for Non-
Exchange Entities," which is incorporated by reference in this Agreement, when
engaging in any activity as a CAC pursuant to 45 CFR 155.225. Staff Member/
Volunteer is thereby bound to strictly adhere to the privacy and security standards,
and to ensure that any Workforce it may have that creates, collects, accesses, stores,
maintains, discloses, or uses PH, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the. efficient
operation of the FEE.
b. Authorized Functions. Staff Member/ Volunteer may create, collect, disclose, access,
maintain, store, and use PII of Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, or these individuals' legal
representative(s) or Authorized Representative(s), in order to:
I. Provide information about the full range of QHP options and Insurance
Affordability Programs for which these persons are eligible;
2. Assist these persons with applications for coverage in a QHP through the FFE and
for Insurance Affordability Programs;
3. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
4. Perform other functions authorized under 45 CFR I 55.225, including functions
substantially similar to those enumerated above, and such other functions that
may be approved by CDO in writing from time to time, but only if CMS has
expressly permitted CDO to carry out those functions.
e. PIT Received. Subject to the teinis and conditions of this Agreement and applicable
laws, in performing the tasks contemplated under this Agreement, Staff Member/
Volunteer may create, collect, disclose, access, maintain, store, and use the following
6

data and PH from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or these individuals' legal representative(s) or
Authorized Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, start and end
dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amOunt
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment. Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birtbdate
Contact Telephone number
Contact Email
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FEE Applicant ID
FFE Member ID
Issuer Member ID
Net premium amount
Pregnancy indicator
Premium Amount, start and end dates
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
7

d. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PH from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), Staff Member/Volunteer will
obtain the authorization required under Section II.a.x.3 of this Agreement to create,
collect, disclose, access, maintain, use, or store their PH to carry out the Authorized
Functions listed at Section III.b of this Agreement, and will permit the authorization
to be revoked at any time. Staff Member/Volunteer may use the model form provided
by CMS and appended hereto and referred to as Appendix E to fulfill this
requirement. This authorization is separate and distinct from any authorization
obtained pursuant to section III.g of this agreement and the informed consent
referenced in Appendix A at 3(a). The CDO should ensure that a record of the
authorization provided is maintained in a manner consistent with the privacy and
security standards set forth in Appendix A.
e. Collection of PII. PIT collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), may be used only for the
Authorized Functions specified in Section III.b of this Agreement. Such information
may not be reused for any other purpose.
f. Storing PII. Other than documentation related to the authorization required by Section
III,d above, Staff Member/Volunteer is not expected or required to maintain or store
any of the above listed PH as a result of carrying out the Authorized Functions
specified in Section III.b above. To the extent that Staff Member/Volunteer does
maintain or store PII, such as documentation related to the authorization required by
Section III.d, he or she must agree to comply with all provisions of this Agreement
and Appendix A that apply to the maintenance or storage of P11.
g. Collection and Use of Information Provided Under Other Authorities. This
Agreement does not preclude Staff Member/Volunteer from separately collecting
information from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such
non-FFE infoimation obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must he separately collected and stored from
any PH collected in accordance with this Agreement. Any authorization for collection
and use of PIT under this provision is separate and distinct from the authorization
obtained pursuant to Section III.d above and and should be obtained and
maintained separately from that authorization.
h. Ability of Consumer to Limit Collection and Use. Staff Member/Volunteer agrees to
allow the Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
Qualified Employer, directly or through their legal representative(s) or Authorized
Representative(s), to limit Staff Member/Volunteer's creation, collection, use,
maintenance, storage, and disclosure of their PE to the sole purpose of obtaining Staff
8

Member/Volunteer's assistance for FFE purposes, and for performing Authorized
Functions specified in Section III.b of this Agreement.
IV. EFFECTIVE DATE: TERM AND RENEWAL.
a. Effective Date and Term. This Agreement becomes effective on the date the last of
the :two Parties signs this Agreement and ends one year from the effective date.
b. Renewal. This Agreement will automatically renew for subsequent and consecutive
one (1) year periods upon the expiration of this Agreement, unless:
i. CDO is no longer designated by CMS; or
CDO, in its sole and absolute discretion, notifies Staff Member/Volunteer
with 30 Days' advance written notice that it has determined that the
Agreement will not be renewed. Such notice will specify whether and under
what conditions - CDO will renew the Agreement; or
CDO terminates the Agreement pursuant to Section V of this Agreement.
V. Termination
a. Termination without Cause. Either Party may terminate this Agreement without
cause upon thirty (30) Days' prior written notice to the other Party.
b. Termination with Cause. This Agreement shall terminate immediately when Staff
Member/Volunteer no longer holds a position as a staff member or volunteer at CDO,
or when CDO withdraws Staff Member/Volunteer's certification as a. CAC, or when
CMS has withdrawn CD0's designation as a CDO. CDO may terminate this
Agreement for cause as soon as possible, but in no event later than twenty (20) Days
after the triggering event (identification or notification of noncompliance) if CDO
learns or is notified by CMS that Staff Member/Volunteer has failed to comply with
the terms and conditions of this Agreement or with any applicable requirements of 45
CFR 155.225, unless Staff Member/Volunteer commences curing such breach(es)
within such 20-Day period to the reasonable satisfaction CDO, and thereafter
diligently implements such cure to completion, The 20-Day notice from CDO shall
contain a description of the material breach, whereupon Staff Member/Volunteer
shall have seven (7) Days from the date of the notice in which to propose a plan and a
time frame to cure the material breach, which plan and time frame may be rejected,
approved or amended in CDO's sole but reasonable discretion. Notwithstanding the
foregoing, Staff Member /Volunteer shall be considered in "Habitual Default" of this
Agreement in the event that it has been served with a 20-Day notice under this
subsection more than three (3) times in any calendar year, whereupon CDO may, in
its sole discretion, immediately thereafter terminate this Agreement upon notice to
Staff Member/Volunteer without any further opportunity to cure or propose cure.
c. Consequences of Teimination or Nonrenewal. If this Agreement is not renewed
pursuant to Section IV.b or is terminated pursuant to Sections V.a or V.b of this
9

Agreement, Staff Member/Volunteer's certification as a CAC is automatically
withdrawn. If that occurs Staff Member/Volunteer must immediately cease holding
himself or herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these individuals'
legal representative(s) or Authorized Representative(s), and must immediately cease
providing CAC services to the public.
VI. DESTRUCTION OF PH. Staff Member/Volunteer covenants and agrees to destroy all
PII in his or her possession at the end of the record retention period required under
Appendix A. If, upon the termination or expiration of this Agreement Staff Member/
Volunteer has in his or her possession PIT for which no retention period is specified in
Appendix A, such PIT shall be destroyed within thirty (30) Days of the tennination or
expiration of this Agreement. Staff Member/Volunteer's duty to protect and maintain the
privacy and security of PH, as provided for in Appg-JA of this Agreement, shall
continue in full force and effect until such PH is destroyed and shall survive the
termination or expiration of this Agreement.
VII. GENERAL PROVISIONS.
a. Assignment and Delegation. Staff Member/Volunteer shall not assign its rights or
delegate its performance under this Agreement. CDO shall not assign its rights or
delegate its performance under this Agreement without the express prior written
consent of CMS.
b. Disclaimer. Neither this Agreement nor the activities of the Parties contemplated
under this Agreement shall be deemed or construed to create in any way any
partnership, joint venture or agency relationship between either or both of the Parties
hereto on one hand and the United States of America (or any of its agencies or
departments) on the other. Neither CDO nor Staff Member/Volunteer is, nor shall
either CDO or Staff Member/Volunteer hold itself out to be, vested with any power,
authority or right to act on behalf of the United States of America in any manner as an
agent or representative thereof, or to bind the United States in any manner or fashion.
c. Amendments. CDO may amend this Agreement for purposes of reflecting changes in
applicable law, regulations, or CMS implementation guidance, with such amendments
taking effect upon thirty (30) Days' written notice to Staff Member/Volunteer ("CDO
notice period"). Staff Member/Volunteer may reject such amendment, by providing
to CDO, during the CDO notice period, thirty (30) Days' written notice of its intent to
reject the amendment ("rejection notice period"). Any such rejection of such
amendment made by CDO for purposes of reflecting changes in applicable law,
regulations, or CMS implementation guidance shall result in the termination of this
Agreement upon expiration of the rejection notice period.
1 0

d. Compliance with Law. CDO and Staff Member/Volunteer shall comply with any and
all applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable to
the conduct of the activities that are the subject of this Agreement, including but not
limited to, any additional and applicable standards required by statute, and any
regulations or policies implementing or interpreting such statutory provisions
hereafter issued by CMS. in the event of a conflict between the terms of this
Agreement and, any statutory, regulatory, or sub-regulatory guidance released by
CMS, the requirement which constitutes the stricter, higher or more stringent level of
compliance controls.
e. [Placeholder for Governing Law provision]
f. [Placeholder for Notices provision
g. [Pla.ceholder for Severability provision
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
11

This "Agreement between CDO and Staff Member/Volunteer has been signed by:
FOR CDO:
By:
[Title of person authorized to enter into
agreements on behalf of organization to bind
the organization]
Date:
FOR Staff Member/Volunteer:
/
Printed Name:
Beverly Leyvas
Date: 72- i3
12

MODEL AGREEMENT BETWEEN CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH THE FEDERALLY-
FACILITATED EXCHANGE IS OPERATING AND CERTIFIED APPLICATION
COUNSELOR
THIS AGREEMENT ("Agreement") is entered into between Maricopa County Department
of Public Health, Health Care for the Homeless, an organization that The Centers for
Medicare & Medicaid Services ("CMS"), which manages and oversees the Federally-facilitated
Exchanges ("EFEs"), has designated as a Certified Application Counselor Designated
Organization in Arizona, a State/States in which an FEE is operating (hereinafter referred to as
"CDO") and Cathy Hollis, a staff member or volunteer of the CDO who wishes to be certified by
the CDO to act as a Certified Application Counselor (hereinafter referred to as "Staff
Member/Volunteer") and to perform the duties and meet the standards and requirements of 45
CFR 155.225. The CDO and Staff Member or Volunteer are hereinafter sometimes referred to
as "Party," or, collectively, as the "Parties."
WHEREAS:
1. Pursuant to 45 CFR 155.225(b), CMS may designate an organization to certify its staff
members or volunteers to act as Certified Application Counselors.
2. CMS has designated CDO to certify staff members and volunteers to act as certified
application counselors in an FFE.
3. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QHP through the FEE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
4. The CDO, and the staff members and volunteers that the CDO certifies as CACs, will
need to create, collect, disclose, access, maintain, store, and/or use the Personally
Identifiable Information ("P11") from CMS, Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) that is necessary to carry out the
Authorized Functions described at III.b below.
5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and

Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s), in order to perfoon the Authorized Functions described in Section
III.b of this Agreement.
6. 45 CFR 155.225(d)(3) requires all CACs to comply with the Exchange's privacy and
security standards adopted consistent with 45 CFR 1 55.260, and applicable
authentication and data security standards.
7. CMS, in the administration of the FFEs, has adopted privacy and security standards
concerning personally identifiable information ("PH") and applicable authentication and
data security standards, which are set forth in A -iendix A, "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities." Compliance
with this Agreement satisfies the requirement under 45 CFR 155.225(d)(3) to comply
with applicable authentication and data security standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
OBLIGATIONS AND CONDITIONS
a, Staff Member/Volunteer's Obligations and Conditions. To carry out the functions
authorized by 45 CFR 155.225, and as a condition of Staff Member/Volunteer's
certification by CDO, Staff Member/Volunteer agrees to the following:
• Prior to functioning as a CAC, Staff Member/Volunteer shall do all of the
following:
Register with CDO and receive a unique identifying number and a
CAC Certificate, in accordance with CD0's procedures [ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL BY REFERENCE RATHER
THAN CREATE ITS OWN PROCEDURES] as set forth in Section 2
of the CAC User Manual, which is incorporated by reference into this
Agreement Appendix C, "CAC User Mannar];
Register for CMS-approved training using Staff Member/Volunteer's
unique CAC identification number and the name that will appear on
both his or her CAC Certificate and Training Certificate;
3. Complete CMS-approved training regarding QHP options, Insurance
Affordability Programs, eligibility, and benefits rules and regulations
2

governing all Insurance Affordability Programs operated in the state,
as implemented in the state;
4. Complete and achieve a passing score on all CMS-approved
certification examinations;
5. Provide proof in the form of his or her printed Training Certificate to
CDO that he or she has fulfilled the training and certification
examination requirements specified in Section II.b.i.2 and 3; and
6. Execute this Agreement.
StaffMember/Volunteer shall disclose to CDO and to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized
Representative(s) any relationship Staff Member/Volunteer has with QHPs or
Insurance Affordability Programs, or other potential conflicts of interest;
iii. [FOR USE ONLY IF THE CDO DECIDES TO REQUIRE THIS] Staff
Member/Volunteer shall disclose to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) any relationship
the CDO has with QHPs or Insurance Affordability Programs, or other
potential conflicts of interest, using language supplied by CDO;
iv. Staff Member/Volunteer shall comply with all provisions of this Agreement
and its attachments, all of which are hereby incorporated by reference,
including Appendix A. "Privacy and Security Standards and Implementation
Specifications for Non-Exchange Entities," which was drafted in conformance
with 45 CPR 155.260;
v. Staff Member/Volunteer shall act in the best interests of any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, or Qualified
Employer that he or she assists;
vi. Staff Member/Volunteer shall, either directly or through an appropriate
referral to a Navigator or non-Navigator assistance personnel authorized under
45 CFR §§ 155.205(d) and (e) or 155.210, or to the Exchange call center
authorized under 45 CFR § 155.205(a), provide information in a manner that
is accessible to individuals with disabilities, as defined by the Americans with
Disabilities Act, as amended, 42 USC § 32101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
vii. Staff Member/Volunteer shall provide infoiluation to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized

Representative(s) about the full range of QHP options and Insurance
Affordability Programs for which they are eligible;
viii. Staff Member/Volunteer shall assist Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) in applying for
coverage in a QHP through the Marketplace and for Insurance Affordability
- Programs;
. Staff Member/Volunteer shall help to facilitate enrollment of eligible
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers in QHPs and Insurance Affordability
Programs;
x. Staff Member/ Volunteer shall follow CDO's established procedures[ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL AND SOPS BY REFERENCE RATHER
THAN DEVELOP OTHER PROCEDURES: as set forth in Appendix C,
"CAC User Manual," and Appendix D, "CAC Standard Operating Procedures
(SOPS)," which are incorporated by reference into this Agreement], to:
1. Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) the CAC
Certificate provided by CDO evidencing the individual's certification
as a CAC each time Staff Member/Volunteer assists any of these
persons;
Inform Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), of the functions and
responsibilities of CACs. Staff Member/Volunteer may use the model
form provided by CMS and appended hereto and referred to as
Appendix E to fulfill this requirement;
3. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PII of Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, Qualified Employers,
and/or these individual's legal representatives(s) or Authorized
Representative(s) obtain the authorization required by 45 CFR
155.225(f) and section III.d of this Agreement (hereinafter referred to
as "authorization") to create, collect, disclose, access, maintain, store,
and use P11 of such person(s) to carry out the Authorized Functions
listed at Section III.b of this Agreement. This authorization may be
obtained either directly from the Consumer, Applicant, Qualified
Individual, Enrollee, Qualified Employee, and/or Qualified Employer,
4

or through such person(s)' legal representative(s) or Authorized
Representative(s). Staff Member/Volunteer may use the model foim
provided by CMS and appended hereto and referred to as Appendix E
to fulfill this requirement. This authorization is separate and distinct
both from any authorization obtained pursuant to section III.g of this
agreement and from the informed consent referenced in Appendix A at
3(a);
4. Maintain a record of the authorization provided under Section II.a.x.3;
5. Permit the Consumer, Applicant, Qualified Individual, Enrollee,
Qualified Employee, and Qualified Employer, and/or their legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section II.a.x.3. at any time;
6. Provide his or her unique CAC identification number to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) assisted by Staff
Member/Volunteer, and include his or her unique CAC identification
number on any application that is partially or fully completed in
connection with Staff Member/Volunteer's assistance for that
individual;
xi, Staff Member/Volunteer shall not impose any charge on any Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s) for application or other assistance related to the Exchange;
xii. Staff Member/Volunteer shall not sell or otherwise transfer information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) to any person or entity
other than such actions as are specifically permitted by this Agreement;
xiii. Staff Member/Volunteer shall not collect or otherwise maintain information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), except as specifically
provided for in this Agreement;
xiv. Upon termination or nonrenewal of Staff Member/Volunteer's agreement with
CDO, Staff Member/Volunteer shall immediately cease holding himself or
herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these
5

individuals' legal representative(s) or Authorized Representative(s), and
immediately cease providing CAC services to the public; and
xv. As evidenced by my signature hereon, I hereby agree to provide the duties and
services described herein without compensation of any kind (other than the
wages I may nonetheless earn as an employee of CDO for work performed on
behalf of my employer), and hereby waive my rights to any fee, remuneration
or compensation to which I might somehow be entitled to receive from the
Government of the United States of America under applicable law.
OBLIGATIONS RELATED TO THE PRIVACY AND SECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION.
a. Staff Member/Volunteer hereby acknowledges and agrees to accept and abide by the
standards and implementation specifications set forth below and in Appendix A,
"Privacy and Security Standards and Implementation Specifications for Non-
Exchange Entities," which is incorporated by reference in this Agreement, when
engaging in any activity as a CAC pursuant to 45 CFR 155.225. Staff Member/
Volunteer is thereby bound to strictly adhere to the privacy and security standards,
and to ensure that any Workforce it may have that creates, collects, accesses, stores,
maintains, discloses, or uses PII, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the efficient
operation of the FEE.
b. Authorized Functions. Staff Member/ Volunteer may create, collect, disclose, access,
maintain, store, and use PII of Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, or these individuals' legal
representative(s) or Authorized Representative(s), in order to:
1. Provide information about the full range of QHP options and Insurance
Affordability Programs for which these persons are eligible;
Assist these persons with applications for coverage in a QHP through the FEE and
for Insurance Affordability Programs;
3. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
4. Perform other functions authorized under 45 CFR 155.225, including functions
substantially similar to those enumerated above, and such other functions that
may be approved by CDO in writing from time to time, but only if CMS has
expressly permitted CDO to carry out those functions.
c. PII Received. Subject to the terms and conditions of this Agreement and applicable
laws, in performing the tasks contemplated under this Agreement, Staff Member/
Volunteer may create, collect, disclose, access, maintain, store, and use the following
6

data and PIT from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or these individuals' legal representative(s) or
Authorized Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, Start and e nd
dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amount
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birthdate
Contact Telephone number
Contact Em all
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FFE Applicant ID
FFE Member ID
Issuer Member ID
Net premium amount
Pregnancy indicator
Premium Amount, start and end dates
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
7

d. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PII from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), Staff Member/Volunteer will
obtain the authorization required under Section Il.a.x.3 of this Agreement to create,
collect, disclose, access, maintain, use, or store their PIT to carry out the Authorized
Functions listed at Section III.b of this Agreement, and will permit the authorization
to be revoked at any time. Staff Member/Volunteer may use the model form provided
by CMS and appended hereto and referred to as Appendix E to fulfill this
requirement. This authorization is separate and distinct from any authorization
obtained pursuant to section III.g of this agreement and the informed consent
referenced in Appendix A at 3(a). The CDO should ensure that a record of the
authorization provided is maintained in a manner consistent with the privacy and
security standards set forth in Appendix A.
e. Collection of PII. PII collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), may be used only for the
Authorized Functions specified in Section III.b of this Agreement. Such information
may not be reused for any other purpose.
f. Storing PH. Other than documentation related to the authorization required by Section
III.d above, Staff Member/Volunteer is not expected or required to maintain or store
any of the above listed PII as a result of cai-rying out the Authorized Functions
specified in Section III.b above. To the extent that Staff Member/Volunteer does
maintain or store PII, such as documentation related to the authorization required by
Section III.d, he or she must agree to comply with all provisions of this Agreement
and Appendix A that apply to the maintenance or storage of P11.
C011ection and Use of Information Provided Under Other Authorities. This
Agreement does not preclude Staff Member/Volunteer from separately collecting
information from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such
non-FEE information obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must be separately collected and stored from
any PII collected in accordance with this Agreement. Any authorization for collection
and use of PII under this provision is separate and distinct from the authorization
obtained pursuant to Section III.d above and II.a.x.3, and should be obtained and
maintained separately from that authorization.
h. Ability of Consumer to Limit Collection and Use. Staff Member/Volunteer agrees to
allow the Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
Qualified Employer, directly or through their legal representative(s) or Authorized
Representative(s), to limit Staff Member/Volunteer's creation, collection, use,
maintenance, storage, and disclosure of their PII to the sole purpose of obtaining Staff
8

Member/Volunteer's assistance for FFE purposes, and for performing Authorized
Functions specified in Section III.b of this Agreement.
IV. EFFECTIVE DATE; TERM AND RENEWAL.
a. Effective Date and Term. This Agreement becomes effective on the date the last of
the two Parties signs this Agreement and ends one year from the effective date.
b. Renewal. This Agreement will automatically renew for subsequent and consecutive
one (1) year periods upon the expiration of this Agreement, unless:
i. CDO is no longer designated by CMS; or
CDO, in its sole and absolute discretion, notifies Staff Member/Volunteer
with 30 Days' advance written notice that it has determined that the
Agreement will not be renewed. Such notice will specify whether and under
what conditions CDO will renew the Agreement; or
CDO terminates the Agreement pursuant to Section V of this Agreement.
V Termination
a. Termination without Cause. Either Party may terminate this Agreement without
cause upon thirty (30) Days' prior written notice to the other Party.
b. Termination with Cause. This Agreement shall terminate immediately when Staff
Member/Volunteer no longer holds a position as a staff member or volunteer at CDO,
or when CDO withdraws Staff Member/Volunteer's certification as a CAC, or when
CMS has withdrawn CDO' s designation as a CDO. CDO may teinfinate this
Agreement for cause as soon as possible, but in no event later than twenty (20) Days
after the triggering event (identification or notification of noncompliance) if CDO
learns or is notified by CMS that Staff Member/Volunteer has failed to comply with
the terms and conditions of this Agreement or with any applicable requirements of 45
CFR 155,225, unless Staff Member/Volunteer commences curing such breach(es)
within such 20-Day period to the reasonable satisfaction CDO, and thereafter
diligently implements such cure to completion. The 20-Day notice from CDO shall
contain a description of the material breach, whereupon Staff Member/Volunteer
shall have seven (7) Days from the date of the notice in which to propose a plan and a
time frame to cure the material breach, which plan and time frame may be rejected,
approved or amended in CDO's sole but reasonable discretion. Notwithstanding the
foregoing, Staff Member /Volunteer shall be considered in "Habitual Default" of this
Agreement in the event that it has been served with a 20-Day notice under this
subsection more than three (3) times in any calendar year, whereupon CDO may, in
its sole discretion, immediately thereafter terminate this Agreement upon notice to
Staff Member/Volunteer without any further opportunity to cure or propose cure.
c. Conseouences of Termination or Nonrenewal. If this Agreement is not renewed
pursuant to Section IV.b or is terminated pursuant to Sections V.a or V.b of this
9

Agreement, Staff Member/Volunteer's certification as a CAC is automatically
withdrawn. If that occurs Staff Member/Volunteer must immediately cease holding
himself or herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these individuals'
legal representative(s) or Authorized Representative(s), and must immediately cease
providing CAC services to the public.
VI. DESTRUCTION OF PII. Staff Member/Volunteer covenants and agrees to destroy all
PH in his or her possession at the end of the record retention period required under
Appendix A. if, upon the tei inination or expiration of this Agreement Staff Member/
Volunteer has in his or her possession PE for which no retention period is specified in
Appendix A, such PII shall be destroyed within thirty (30) Days of the termination or
expiration of this Agreement. Staff Member/Volunteer's duty to protect and maintain the
privacy and security of PII, as provided for in Appendix A of this Agreement, shall
continue in full force and effect until such PII is destroyed and shall survive the
termination or expiration of this Agreement.
VII. GENERAL PROVISIONS.
a. Assignment and Delegation. Staff Member/Volunteer shall not assign its rights or
delegate its performance under this Agreement. CDO shall not assign its rights or
delegate its performance under this Agreement without the express prior written
consent of CMS.
b. Disclaimer. Neither this Agreement nor the activities of the Parties contemplated
under this Agreement shall be deemed or construed to create in any way any
partnership, joint venture or agency relationship between either or both of the Parties
hereto on one hand and the United States of America (or any of its agencies or
departments) on the other. Neither CDO nor Staff Member/Volunteer is, nor shall
either CDO or Staff Member/Volunteer hold itself out to be, vested with any power,
authority or right to act on behalf of the United States of America in any manner as an
agent or representative thereof, or to bind the United States in any manner or fashion.
c. Amendments. CDO may amend this Agreement for purposes of reflecting changes in
applicable law, regulations, or CMS implementation guidance, with such amendments
taking effect upon thirty (30) Days' written notice to Staff Member/Volunteer ("CDO
notice period"). Staff Member/Volunteer may reject such amendment, by providing
to CDO, durin.g the CDO notice period, thirty (30) Days' written notice of its intent to
reject the amendment ("rejection notice period"). Any such rejection of such
amendment made by CDO for purposes of reflecting changes in applicable law,
regulations, or CMS implementation guidance shall result in the termination of this
Agreement upon expiration of the rejection notice period.
10

d. Compliance with Law. CDO and Staff Member/Volunteer shall comply with any and
all applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable to
the conduct of the activities that are the subject of this Agreement, including but not
limited to, any additional and applicable standards required by statute, and any
regulations or policies implementing or interpreting such statutory provisions
hereafter issued by CMS. In the event of a conflict between the terms of this
Agreement and, any statutory, regulatory; or sub-regulatory .guidance released by
CMS, the requirement which constitutes the stricter, higher or more stringent level of
compliance controls.
e. [Placeholder for Governing Law provision.
[Placeholder for Notices provision]
g. [Pla.ceholder for Severability provision
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
11

This "Agreement between CDO and Staff Member/Volunteer has been signed by:
FOR CDO:
By:
[Title of person authorized to enter into
agreements on behalf of organization to bind
the organization]
Date:
FOR Staff Member/Volunteer:
By:
Printed Name:
Cathy Hollis
Date:
12

MODEL AGREEMENT BETWEEN CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH THE FEDERALLY-
FACILITATED EXCHANGE IS OPERATING AND CERTIFIED APPLICATION
COUNSELOR
THIS AGREEMENT ("Agreement") is entered into between Maricopa County Department
of Public Health, Health Care for the Homeless, an organization that The Centers for
Medicare & Medicaid Services ("CMS"), which manages and oversees the Federally-facilitated
Exchanges ("FFEs"), has designated as a Certified Application Counselor Designated
Organization in Arizona, a State/States in which an FFE is operating (hereinafter referred to as
"CDO") and Brian Olivas, a staff member or volunteer of the CDO who wishes to be certified
by the CDO to act as a Certified Application Counselor (hereinafter referred to as "Staff
Member/Volunteer") and to perform the duties and meet the standards and requirements of 45
CFR 155.225. The CDO and Staff Member or Volunteer are hereinafter sometimes referred to
as "Party," or, collectively, as the "Parties."
WHEREAS:
1. Pursuant to 45 CFR 155.225(b), CMS may designate an organization to certify its staff
members or volunteers to act as Certified Application Counselors.
2. CMS has designated CDO to certify staff members and volunteers to act as certified
application counselors in an FFE.
3. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QHP through the FFE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
4. The CDO, and the staff members and volunteers that the CDO certifies as CACs, will
need to create, collect, disclose, access, maintain, store, and/or use the Personally
Identifiable Information ("PII") from CMS, Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) that is necessary to carry out the
Authorized Functions described at III.b below.
5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and
use PIT from CMS, Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
1

Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s), in order to perform the Authorized Functions described in Section
III.b of this Agreement.
6. 45 CFR 155.225(d)(3) requires all CACs to comply with the Exchange's privacy and
security standards adopted consistent with 45 CFR 155.260, and applicable
authentication and data security standards.
7. CMS, in the administration of the FFEs, has adopted privacy and security standards
concerning personally identifiable information ("PIT") and applicable authentication and
data security standards, which are set forth in Appendix A, "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities." Compliance
with this Agreement satisfies the requirement under 45 CFR I55.225(d)(3) to comply
with applicable authentication and data security standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
I. DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
II. OBLIGATIONS AND CONDITIONS
a. Staff Member/Volunteer's Oblivations and Conditions. To carry out the fanations
authorized by 45 CFR 155.225, and as a condition of Staff Member/Volunteer's
certification by CDO, Staff Member/Volunteer agrees to the following:
i. Prior to functioning as a CAC, Staff Member/Volunteer shall do all of the
following:
Register with CDO and receive a unique identifying number and a
CAC Certificate, in accordance with CD0's procedures [ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL BY REFERENCE RATHER
THAN CREATE ITS OWN PROCEDURES] as set forth in Section 2
of the CAC User Manual, which is incorporated by reference into this
Agreement Appendix C, "CAC User Manual"];
Register for CMS-approved training using Staff Member/Volunteers
unique CAC identification number and the name that will appear on
both his or her CAC Certificate and Training Certificate;
3. Complete CMS-approved training regarding QHP options, Insurance
Affordability Programs, eligibility, and benefits rules and regulations
2

governing all Insurance Affordability Programs operated in the state,
as implemented in the state;
4. Complete and achieve a passing score on all CMS-approved
certification examinations;
5. Provide proof in the form of his or her printed Training Certificate to
CDO that he or she has fulfilled the training and certification
examination requirements specified in Section II.b.i.2 and 3; and
6. Execute this Agreement.
ii. Staff Member/Volunteer shall disclose to CDO and to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized
Representative(s) any relationship Staff Member/Volunteer has with QHPs or
Insurance Affordability Programs, or other potential conflicts of interest;
iii. [FOR USE ONLY IF THE CDO DECIDES TO REQUIRE THIS] Staff
Member/Volunteer shall disclose to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) any relationship
the CDO has with QHPs or Insurance Affordability Programs, or other
potential conflicts of interest, using language supplied by CDO;
iv. Staff Member/Volunteer shall comply with all provisions of this Agreement
and its attachments, all of which are hereby incorporated by reference,
including Appendix A, "Privacy and Security Standards and Implementation
Specifications for Non-Exchange Entities," which was drafted in conformance
with 45 CFR 155.260;
v. Staff Member/Volunteer shall act in the best interests of any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, or Qualified
Employer that be or she assists;
vi. Staff Member/Volunteer shall, either directly or through an appropriate
referral to a Navigator or non-Navigator assistance personnel authorized under
45 CFR §§ 155.205(d) and (e) or 155.210, or to the Exchange call center
authorized under 45 CFR § 155.205(a), provide information in a manner that
is accessible to individuals with disabilities, as defined by the Americans with
Disabilities Act, as amended, 42 USC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 liSC § 794;
vii. Staff Member/Volunteer shall provide information to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized

Representative(s) about the full range of QHP options and Insurance
Affordability Programs for which they are eligible;
viii. Staff Member/Volunteer shall assist Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) in applying for
coverage in a QHP through the Marketplace and for Insurance Affordability
Programs;
ix. Staff Member/Volunteer shall help to facilitate enrollment of eligible
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers in QHPs and Insurance Affordability
Programs;
Staff Member/ Volunteer shall follow CDO' s established procedures[ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL AND SOPS BY REFERENCE RATHER
THAN DEVELOP OTHER PROCEDURES] as set forth in Appendix C,
"CAC User Manual," and Appendix D, "CAC Standard Operating Procedures
(SOPs)," which are incorporated by reference into this Agreement], to:
I. Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) the CAC
Certificate provided by CDO evidencing the individual's certification
as a CAC each time Staff Member/Volunteer assists any of these
persons;
Inform Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), of the functions and
responsibilities of CACs. Staff Member/Volunteer may use the model
form provided by CMS and appended hereto and referred to as
Appendix E to fulfill this requirement;
3. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any P11 of Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, Qualified Employers,
and/or these individual's legal representatives(s) or Authorized
Representative(s) obtain the authorization required by 45 CFR
155.225(f) and section III.d of this Agreement (hereinafter referred to
as "authorization") to create, collect, disclose, access, maintain, store,
and use PH of such person(s) to carry out the Authorized Functions
listed at Section III.b of this Agreement. This authorization may be
obtained either directly from the Consumer, Applicant, Qualified
Individual, Enrollee, Qualified Employee, and/or Qualified Employer,
4

or through such person(s)' legal representative(s) or Authorized
Representative(s). Staff Member/Volunteer may use the model form
provided by CMS and appended hereto and referred to as Appendix E
to fulfill this requirement. This authorization is separate and distinct
both from any authorization obtained pursuant to section III.g of this
agreement and from the informed consent referenced in Appendix A at
3(a);
4. Maintain a record of the authorization provided under Section Il.a.x.3;
5. Permit the Consumer, Applicant, Qualified Individual, Enrollee,
Qualified Employee, and Qualified Employer, and/or their legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section II.a.x.3. at any time;
6. Provide his or her unique CAC identification number to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) assisted by Staff
Member/Volunteer, and include his or her unique CAC identification
number on any application that is partially or fully completed in
connection with Staff Member/Volunteer's assistance for that
individual;
xi. Staff Member/Volunteer shall not impose any charge on any Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s) for application or other assistance related to the Exchange;
xii. Staff Member/Volunteer shall not sell or otherwise transfer information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) to any person or entity
other than such actions as are specifically permitted by this Agreement;
xiii. Staff Member/Volunteer shall not collect or otherwise maintain information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), except as specifically
provided for in this Agreement;
xiv. Upon termination or nonrenewal of Staff Member/Volunteer's agreement with
CDO, Staff Member/Volunteer shall immediately cease holding himself or
herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these
5

individuals' legal representative(s) or Authorized Representative(s), and
immediately cease providing CAC services to the public; and
xv. As evidenced by my signature hereon, I hereby agree to provide the duties and
services described herein without compensation of any kind (other than the
wages I may nonetheless earn as an employee of CDO for work performed on
behalf of my employer), and hereby waive my rights to any fee, remuneration
or compensation to which I might somehow be entitled to receive from the
Government of the United States of America under applicable law.
III. OBLIGATIONS RELATED TO THE PRIVACY ANDSECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION.
a. Staff Member/Volunteer hereby acknowledges and agrees to accept and abide by the
standards and implementation specifications set forth below and in Appendix A,
"Privacy and Security Standards and Implementation Specifications for Non-
Exchange Entities," which is incorporated by reference in this Agreement, when
engaging in any activity as a CAC pursuant to 45 CFR 155.225. Staff Member/
Volunteer is thereby bound to strictly adhere to the privacy and security standards,
and to ensure that any Workforce it may have that creates, collects, accesses, stores,
maintains, discloses, or uses PII, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the efficient
operation of the FFE.
b. Authorized Functions. Staff Member/ Volunteer may create, collect, disclose, access,
maintain, store, and use PIT of Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, or these individuals' legal
representative(s) or Authorized Representative(s), in order to:
1. Provide information about the full range of QHP options and Insurance
Affordability Programs for which these persons are eligible;
2. Assist these persons with applications for coverage in a QHP through the FEE and
for Insurance Affordability Programs;
3. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
4. Perform other functions authorized under 45 CFR 155.225, including functions
substantially similar to those enumerated above, and such other functions that
may be approved by CDO in writing from time to time, but only if CMS has
expressly permitted CDO to carry out those functions.
c. PI] Received. Subject to the terms and conditions of this Agreement and applicable
laws, in perfoiniing the tasks contemplated under this Agreement, Staff Member/
Volunteer may create, collect, disclose, access, maintain, store, and use the following
6

data and PII from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or these individuals' leg -al representative(s) or
Authorized Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, start and end
dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amount
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birthdate
Contact Telephone number
Contact Email
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FFE Applicant ID
FFE Member ID
Issuer Member ID
Net premium amount
Pregnancy indicator
Premium Amount, start and end dates
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
7

d. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any P11 from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), Staff Member/Volunteer will
obtain the authorization required under Section II.a.x.3 of this Agreement to create,
collect, disclose, access, maintain, use, or store their PIT to carry out the Authorized
Functions listed at Section III.b of this Agreement, and will permit the authorization
to be revoked at any time. Staff Member/Volunteer may use the model form provided
by CMS and appended hereto and referred to as Appendix E to fulfill this
requirement. This authorization is separate and distinct from any authorization
obtained pursuant to section 111.g of this agreement and the informed consent
referenced in Appendix A at 3(a). The CDO should ensure that a record of the
authorization provided is maintained in a manner consistent with the privacy and
security standards set forth in Appendix A.
c. Collection of PII. PIT collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), may be used only for the
Authorized Functions specified in Section III.b of this Agreement. Such information
may not be reused for any other purpose.
f. Storing PII. Other than documentation related to the authorization required by Section
III.d above, Staff Member/Volunteer is not expected or required to maintain or store
any of the above listed P11 as a result of carrying out the Authorized Functions
specified in Section III.b above. To the extent that Staff Member/Volunteer does
maintain or store PII, such as documentation related to the authorization required by
Section III.d, he or she must agree to comply with all provisions of this Agreement
and Appendix A that apply to the maintenance or storage of PH.
g. Collection and Use of Information Provided Under Other Authorities. This
Agreement does not preclude Staff Member/Volunteer from separately collecting
information from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such
non-FFE information obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must be separately collected and stored from
any PIT collected in accordance with this Agreement. Any authorization for collection
and use of PIT under this provision is separate and distinct from the authorization
obtained pursuant to Section III.d above and II.a.x.3, and should be obtained and
maintained separately from that authorization.
h. Ability of Consumer to Limit Collection and Use. Staff Member/Volunteer agrees to
allow the Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
Qualified Employer, directly or through their legal representative(s) or Authorized
Representative(s), to limit Staff Member/Volunteer's creation, collection, use,
maintenance, storage, and disclosure of their PII to the sole purpose of obtaining Staff
8

Member/Volunteer's assistance for FFE purposes, and for performing Authorized
Functions specified in Section 'lab of this Agreement.
IV. EFFECTIVE DATE; TERM AND RENEWAL.
a. Effective Date and Teiiii. This Agreement becomes effective on the date the last of
the two Parties signs this Agreement and ends one year from the effective date.
b. Renewal. This Agreement will automatically renew for subsequent and consecutive
one (1) year periods upon the expiration of this Agreement, unless:
i. CDO is no longer designated by CMS; or
CDO, in its sole and absolute discretion, notifies Staff Member/Volunteer
with 30 Days' advance written notice that it has detei mined that the
Agreement will not be renewed. Such notice will specify whether and under
what conditions CDO will renew the Agreement; or
CDO terminates the Agreement pursuant to Section V of this Agreement.
V. Termination
a. Termination without Cause. Either Party may terminate this Agreement without
cause upon thirty (30) Days' prior written notice to the other Party.
b. Teiniination with Cause. This Agreement shall terminate immediately when Staff
Member/Volunteer no longer holds a position as a staff member or volunteer at CDO,
or when CDO withdraws Staff Member/Volunteer's certification as a CAC, or when
CMS has withdrawn CDO's designation as a CDO. CDO may teiminate this
Agreement for cause as soon as possible, but in no event later than twenty (20) Days
after the triggering event (identification or notification of noncompliance) if CDO
learns or is notified by CMS that Staff Member/Volunteer has failed to comply with
the terms and conditions of this Agreement or with any applicable requirements of 45
CFR 155.225, -unless Staff Member/Volunteer commences curing such breach(es)
within such 20-Day period to the reasonable satisfaction CDO, and thereafter
diligently implements such cure to completion. The 20-Day notice from CDO shall
contain a description of the material breach, whereupon Staff Member/Volunteer
shall have seven (7) Days from the date of the notice in which to propose a plan and a
time frame to cure the material breach, which plan and time frame may be rejected,
approved or amended in CDO's sole but reasonable discretion. Notwithstanding the
foregoing, Staff Member /Volunteer shall be considered in "Habitual Default" of this
Agreement in the event that it has been served with a 20-Day notice under this
subsection more than three (3) times in any calendar year, whereupon CDO may, in
its sole discretion, immediately thereafter terminate this Agreement upon notice to
Staff Member/Volunteer without any further opportunity to cure or propose cure.
c. Consequences of Termination or Nonrenewal. If this Agreement is not renewed
pursuant to Section IV.b Or is terminated pursuant to Sections V.a or V.b of this
9

Agreement, Staff Member/Volunteer's certification as a CAC is automatically
withdrawn. If that occurs Staff Member/Volunteer must immediately cease holding
himself or herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these individuals'
legal representative(s) or Authorized Representative(s), and must immediately cease
providing CAC services to the public.
VI. DESTRUCTION OF PII. Staff Member/Volunteer covenants and agrees to destroy all
PII in his or her possession at the end of the record retention period required under
A_ppendix A. if, upon the termination or expiration of this Agreement Staff Member/
Volunteer has in his or her possession PIT for which no retention period is specified in
Appendix A, such PII shall be destroyed within thirty (30) Days of the teimination or
expiration of this Agreement. Staff Member/Volunteer's duty to protect and maintain the
privacy and security of PII, as provided for in Appendix A of this Agreement, shall
continue in full force and effect until such PII is destroyed and shall survive the
termination or expiration of this Agreement.
VII. GENERAL PROVISIONS.
a. Assignment and Delegation. Staff Member/Volunteer shall not assign its rights or
delegate its performance under this Agreement. CDO shall not assign its rights or
delegate its performance under this Agreement without the express prior written
consent of CMS.
b. Disclaimer. Neither this Agreement nor the activities of the Parties contemplated
under this Agreement shall be deemed or construed to create in any way any
partnership, joint venture or agency relationship between either or both of the Parties
hereto on one hand and the United States of America (or any of its agencies or
departments) on the other. Neither CDO nor Staff Member/Volunteer is, nor shall
either CDO or Staff Member/Volunteer hold itself out to be, vested with any power,
authority or right to act on behalf of the United States of America in any manner as an
agent or representative thereof, or to bind the United States in any manner or fashion.
c. Amendments. CDO may amend this Agreement for purposes of reflecting changes in
applicable law, regulations, or CMS implementation guidance, with such amendments
taking effect upon thirty (30) Days' written notice to Staff Member/Volunteer ("CDO
notice period"). Staff Member/Volunteer may reject such amendment, by providing
to CDO, during the CDO notice period, thirty (30) Days' written notice of its intent to
reject the amendment ("rejection notice period"). Any such rejection of such
amendment made by CDO for purposes of reflecting changes in applicable law,
regulations, or CMS implementation guidance shall result in the termination of this
Agreement upon expiration of the rejection notice period.
10

d. Compliance with Law. CDO and Staff Member/Volunteer shall comply with any and
all applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable to
the conduct of the activities that are the subject of this Agreement, including but not
limited to, any additional and applicable standards required by statute, and any
regulations or policies implementing or interpreting such statutory provisions
hereafter issued by CMS. In the event of a conflict between the terms of this
Agreement and, any statutory, regulatory, or sub-regulatory guidance released by
CMS, the requirement which constitutes the stricter, higher or more stringent level of
compliance controls.
e. [Placeholder for Governing Law provision]
E [Placeholder for Notices provision
g. [Placeholder for Seyerability provision]
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
11

This "Agreement between CDO and Staff Member/Volunteer has been signed by:
FOR CDO:
By:
[Title of person authorized to enter into
agreements on behalf of organization to bind
the organizationj
Date:
FOR Staff Member/Volunteer:
Printed Name:
Brian Olivas
Date: ?--;?-7—L--7
12

MODEL AGREEMENT BETWEEN CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH THE FEDERALLY-
FACILITATED EXCHANGE IS OPERATING AND CERTIFIED APPLICATION
COUNSELOR
THIS AGREEMENT ("Agreement") is entered into between Marieopa County Department
of Public Health, Health Care for the Homeless, an organization that The Centers for
Medicare & Medicaid Services ("CMS''), which manages and oversees the Federally-facilitated
Exchanges ("FFEs"), has designated as a Certified Application Counselor Designated
Organization in Arizona, a State/States in which an FFE is operating (hereinafter referred to as
"CDO") and Alvecla Danks, a staff member or volunteer of the CDO who wishes to be certified
by the CDO to act as a Certified Application Counselor (hereinafter referred to as "Staff
Member/Volunteer") and to perform the duties and meet the standards and requirements of 45
CFR 155.225. The CDO and Staff Member or Volunteer are hereinafter sometimes referred to
as "Party," or, collectively, as the "Parties."
WHEREAS:
1. Pursuant to 45 CFR 155.225(b), CMS may designate an organization to certify its staff
members or volunteers to act as Certified Application Counselors.
2. CMS has designated CDO to certify staff members and volunteers to act as certified
application counselors in an FFE.
3. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QHP through the FFE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
4. The CDO, and the staff members and volunteers that the CDO certifies as CACs, will
need to create, collect, disclose, access, maintain, store, and/or use the Personally
Identifiable Information ("PIT") from CMS, Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) that is necessary to carry out the
Authorized Functions described at III.b below.
5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and
1

Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s), in order to perform the Authorized Functions described in Section
III.b of this Agreement.
6. 45 CFR 155.225(d)(3) requires all CACs to comply with the Exchange's privacy and
security standards adopted consistent with 45 CFR 155.260, and applicable
authentication and data security standards.
7. CMS, in the administration of the FFEs, has adopted privacy and security standards
concerning personally identifiable information ("PIP') and applicable authentication and
data security standards, which are set forth in Appendix A, "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities." Compliance
with this Agreement satisfies the requirement under 45 CFR 155.225(d)(3) to comply
with applicable authentication and data security standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
I. DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
II. OBLIGATIONS AND CONDITIONS
a. Staff Member/Volunteer's Obligations and Conditions. To carry out the functions
authorized by 45 CFR 155.225, and as a condition of Staff Member/Volunteer's
certification by CDO, Staff Member/Volunteer agrees to the following:
Prior to functioning as a CAC, Staff Member/Volunteer shall do all of the
following:
1. Register with CDO and receive a unique identifying number and a
CAC Certificate, in accordance with CDO's procedures [ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL BY REFERENCE RATHER
THAN CREATE ITS OWN PROCEDURES] as set forth in Section 2
of the CAC User Manual, which is incorporated by reference into this
Agreement Appendix C, "CAC User Mar -man;
2. Register for CMS-approved training using Staff Member/Volunteer's
unique CAC identification number and the name that will appear on
both his or her CAC Certificate and Training Certificate;
3. Complete CMS-approved training regarding QHP options, insurance
Affordability Programs, eligibility, and benefits rules and regulations
2

governing all Insurance Affordability Programs operated in the state,
as implemented in the state;
4. Complete and achieve a passing score on all CMS-approved
certification examinations;
5. Provide proof in the form of his or her printed Training Certificate to
CDO that he or she has fulfilled the training and certification
examination requirements specified in Section II.b.i.2 and 3; and
6. Execute this Agreement.
ii. Staff Member/Volunteer shall disclose to CDO and to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized
Representative(s) any relationship Staff Member/Volunteer has with QHPs or
Insurance Affordability Programs, or other potential conflicts of interest;
iii. [FOR USE ONLY IF THE CDO DECIDES TO REQUIRE THIS] Staff
Member/Volunteer shall disclose to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) any relationship
the CDO has with QHPs or Insurance Affordability Programs, or other
potential conflicts of interest, using language supplied by CDO;
iv. Staff Member/Volunteer shall comply with all provisions of this Agreement
and its attachments, all of which are hereby incorporated by reference,
including Appendix A, "Privacy and Security Standards and Implementation
Specifications for Non-Exchange Entities," which was drafted in conformance
with 45 CFR 155.260;
v. Staff Member/Volunteer shall act in the best interests of any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, or Qualified
Employer that he or she assists;
vi. Staff Member/Volunteer shall, either directly or through an appropriate
referml to a Navigator or non-Navigator assistance personnel authorized under
45 CFR §§ 155.205(d) and (e) or 155.210, or to the Exchange call center
authorized under 45 CFR § 155.205(a), provide information in a manner that
is accessible to individuals with disabilities, as defined by the Americans with
Disabilities Act, as amended, 42 USC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
vii. Staff Member/Volunteer shall provide infoituation to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized

Representative(s) about the full range of QHP options and Insurance
Affordability Pro gams for which they are eligible;
viii. Staff Member/Volunteer shall assist Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) in applying for
coverage in a QHP through the Marketplace and for Insurance Affordability
Programs;
ix. Staff Member/Volunteer shall help to facilitate enrollment of eligible
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers in QHPs and Insurance Affordability
Programs;
x. Staff Member/ Volunteer shall follow CDO' s established procedures[ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL AND SOPS BY REFERENCE RATHER
THAN DEVELOP OTHER PROCEDURES] as set forth in Appendix C,
"CAC User Manual," and Appendix D,"CAC Standard Operating Procedures
(SOPs)," which are incorporated by reference into this Agreement], to:
1. Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) the CAC
Certificate provided by CDO evidencing the individual's certification
as a CAC each time Staff Member/Volunteer assists any of these
persons;
2. Inform Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), of the functions and
responsibilities of CACs. Staff Member/Volunteer may use the model
form provided by CMS and appended hereto and referred to as
Appendix E to fulfill this requirement;
3. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any P11 of Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, Qualified Employers,
and/or these individual's legal representatives(s) or Authorized
Representative(s) obtain the authorization required by 45 CFR
155.225(f) and section III.d of this Agreement (hereinafter referred to
as "authorization") to create, collect, disclose, access, maintain, store,
and use PII of such person(s) to carry out the Authorized Functions
listed at Section III.b of this Agreement. This authorization may be
obtained either directly from the Consumer„ Applicant, Qualified
Individual, Enrollee, Qualified Employee, and/or Qualified Employer,
4

or through such person(s)' legal representative(s) or Authorized
Representative(s). Staff Member/Volunteer may use the model form
provided by CMS and appended hereto and referred to as Appendix E
to fulfill this requirement. This authorization is separate and distinct
both from any authorization obtained pursuant to section 111.g of this
agreement and from the informed consent referenced in Appendix A at
3 (a);
4. Maintain a record of the authorization provided under Section II.a.x.3;
5. Permit the Consumer, Applicant, Qualified Individual, Enrollee,
Qualified Employee, and Qualified Employer, and/or their legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section II.a.x.3. at any time;
6. Provide his or her unique CAC identification number to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) assisted by Staff
Member/Volunteer, and include his or her unique CAC identification
number on any application that is partially or fully completed in
connection with Staff Member/Volunteer's assistance for that
individual;
xi. Staff Member/Volunteer shall not impose any charge on any Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s) for application or other assistance related to the Exchange;
xii. Staff Member/Volunteer shall not sell or otherwise transfer information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) to any person or entity
other than such actions as are specifically permitted by this Agreement;
xiii. Staff Member/Volunteer shall not collect or otherwise maintain information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), except as specifically
provided for in this Agreement;
xiv. Upon termination or nonrenewal of Staff Member/Volunteer's agreement with
CDO, Staff Member/Volunteer shall immediately cease holding himself or
herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these
5

individuals' legal representative(s) or Authorized Representative(s), and
immediately cease providing CAC services to the public; and
xv. As evidenced by my signature hereon. I hereby agree to provide the duties and
services described herein without compensation of any kind (other than the
wages I may nonetheless earn as an employee of CDO for work performed on
behalf of my employer), and hereby waive my rights to any fee, remuneration
or compensation to which I might somehow be entitled to receive from the
Government of the United States of America under applicable law.
III OBLIGATIONS RELATED TO THE PRIVACY AND SECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION.
a. Staff Member/Volunteer hereby acknowledges and agrees to accept and abide by the
standards and implementation specifications set forth below and in Appendix A,
"Privacy and Security Standards and Implementation Specifications for Non
Exchange Entities," which is incorporated by reference in this Agreement, when
engaging in any activity as a CAC pursuant to 45 CFR 155.225, Staff Member/
Volunteer is thereby bound to strictly adhere to the privacy and security standards,
and to ensure that any Workforce it may have that creates, collects, accesses, stores,
maintains, discloses, or uses PII, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the efficient
operation of the FFE.
b. Authorized Functions. Staff M tuber/ Volunteer may create, collect, disclose, access,
maintain, store, and use PII of Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, or these individuals' legal
representative(s) or Authorized Representative(s), in order to:
1. Provide infoll iation about the full range of QHP options and Insurance
Affordability Programs for which these persons are eligible;
Assist these persons with applications for coverage in a QHP through the FFE and
for Insurance Affordability Programs;
3. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
4. Perform other functions authorized under 45 CFR 155.225, including functions
substantially similar to those enumerated above, and such other functions that
may be approved by CDO in writing from time to time, but only if CMS has
expressly permitted CDO to carry out those functions.
e. PII Received. Subject to the terms and conditions of this Agreement and applicable
laws, in performing the tasks contemplated under this Agreement, Staff Member/
Volunteer may create, collect, disclose, access, maintain, store, and use the following
6

data and PII from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or these individuals' legal representative(s) or
Authorized Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, start and end
dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amount
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birthdate
Contact Telephone number
Contact Email
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FEE Applicant ID
FFE Member ID
Issuer Member ID
Net premium amount
Pregnancy indicator
Premium Amount, start and end dates
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
7

d. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PII from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), Staff Member/Volunteer will
obtain the authorization required under Section II.a.x.3 of this Agreement to create,
collect, disclose, access, maintain, use, or store their PII to carry out the Authorized
Functions listed at Section III.b of this Agreement, and will permit the authorization
to be revoked at any time. Staff Member/Volunteer may use the model form provided
by CMS and appended hereto and referred to as Appendix E to fulfill this
requirement. This authorization is separate and distinct from any authorization
obtained pursuant to section III.g of this agreement and the informed consent
referenced in Appendix A at 3(a). The CDO should ensure that a record of the
authorization provided is maintained in a manner consistent with the privacy and
security standards set forth in Appendix A.
e. Collection of PII. PIT collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), may be used only for the
Authorized Functions specified in Section III.b of this Agreement. Such information
may not be reused for any other purpose.
Storing PII. Other than documentation related to the authorization required by Section
III.d above, Staff Member/Volunteer is not expected or required to maintain or store
any of the above listed PIT as a result of carrying out the Authorized Functions
specified in Section III.b above. To the extent that Staff Member/Volunteer does
maintain or store PII, such as documentation related to the authorization required by
Section III.d, he or she must agree to comply with all provisions of this Agreement
and Appendix A that apply to the maintenance or storage of PIT.
g. Collection and Use of Information Provided Under Other Authorities. This
Agreement does not preclude Staff Member/Volunteer from separately collecting
infoimation from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such
non-FFE information obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must be separately collected and stored from
any P11 collected in accordance with this Agreement. Any authorization for collection
and use of PIT under this provision is separate and distinct from the authorization
obtained pursuant to Section III.d above and II.a.x.3, and should be obtained and
maintained separately from that authorization.
h. Ability of Consumer to Limit Collection and Use. Staff Member/Volunteer agrees to
allow the Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
Qualified Employer, directly or through their legal representative(s) or Authorized
Representative(s), to limit Staff Member/Volunteer's creation, collection, use,
maintenance, storage, and disclosure of their PII to the sole purpose of obtaining Staff

Member/Volunteer's assistance for FFE purposes, and for performing Authorized
Functions specified in Section III.b of this Agreement.
IV. EFFECTIVE DATE; TERM AND RENEWAL.
a. Effective Date and Term. This Agreement becomes effective on the date the last of
the two Parties signs this Agreement and ends one year from the effective date.
b. Renewal. This Agreement will automatically renew for subsequent and consecutive
one (1) year periods upon the expiration of this Agreement, unless:
i. CDO is no longer designated by CMS; or
CDO, in its sole and absolute discretion, notifies Staff Member/Volunteer
with 30 Days' advance written notice that it has determined that the
Agreement will not be renewed. Such notice will specify whether and under
what conditions CDO will renew the Agreement; or
CDO terminates the Agreement pursuant to Section V of this Agreement.
V. Termination
a. Termination without Cause. Either Party may terminate this Agreement without
cause upon thirty (30) Days' prior written notice to the other Party.
b. Termination with Cause. This Agreement shall teiminate immediately when Staff
Member/Volunteer no longer holds a position as a staff member or volunteer at CDO,
or when CDO withdraws Staff Member/Volunteer's certification as a CAC, or when
CMS has withdrawn CD0's designation as a CDO. CDO may teiminate this
Agreement for cause as soon as possible, but in no event later than twenty (20) Days
after the triggering event (identification or notification of noncompliance) if CDO
learns or is notified by CMS that Staff Member/Volunteer has failed to comply with
the terms and conditions of this Agreement or with any applicable requirements of 45
CFR 155.225, unless Staff Member/Volunteer commences curing such breach(es)
within such 20-Day period to the reasonable satisfaction CDO, and thereafter
diligently implements such cure to completion. The 20-Day notice from CDO shall
contain a description of the material breach, whereupon Staff Member/Volunteer
shall have seven (7) Days from the date of the notice in which to propose a plan and a
time frame to cure the material breach, which plan and time frame may be rejected,
approved or amended in CDO's sole but reasonable discretion. Notwithstanding the
foregoing, Staff Member /Volunteer shall be considered in "Habitual Default" of this
Agreement in the event that it has been served with a 20-Day notice under this
subsection more than three (3) times in any calendar year, whereupon CDO may, in
its sole discretion, immediately thereafter terminate this Agreement upon notice to
Staff Member/Volunteer without any further opportunity to cure or propose cure.
c. Consequences of Termination or Nonrenewal. if this Agreement is not renewed
pursuant to Section IV.b or is terminated pursuant to Sections V.a or V.b of this
9

Agreement, Staff Member/Volunteer's certification as a CAC is automatically
withdrawn. If that occurs Staff Member/Volunteer must immediately cease holding
himself or herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these individuals'
legal representative(s) or Authorized Representative(s), and must immediately cease
providing CAC services to the public.
VI. DESTRUCTION OF P11. Staff Member/Volunteer covenants and agrees to destroy all
PIT in his or her possession at the end of the record retention period required under
Appendix A. If, upon the termination or expiration of this Agreement Staff Member/
Volunteer has in his or her possession Pll for which no retention period is specified in
Appendix A, such P11 shall be destroyed within thirty (30) Days of the termination or
expiration of this Agreement. Staff Member/Volunteer's duty to protect and maintain the
privacy and security of PI1, as provided for in Appendix A of this Agreement, shall
continue in full force and effect until such P11 is destroyed and shall survive the
termination or expiration of this Agreement.
VII. GENERAL PROVISIONS.
a. Assignment and Delegation. Staff Member/Volunteer shall not assign its rights or
delegate its performance under this Agreement. CDO shall not assign its rights or
delegate its performance under this Agreement without the express prior written
consent of CMS.
b. Disclaimer. Neither this Agreement nor the activities of the Parties contemplated
under this Agreement shall be deemed or construed. to create in any way any
partnership, joint venture or agency relationship between either or both of the Parties
hereto on one hand and the United States of America (or any of its agencies or.
departments) on the other. Neither CDO nor Staff Member/Volunteer is, nor shall
either CDO or Staff Member/Volunteer hold itself out to be, vested with any power,
authority or right to act on behalf of the United States of America in any manner as an
agent or representative thereof, or to bind the United States in any manner or fashion.
c. Amendments. CDO may amend this Agreement for purposes of reflecting changes in
applicable law, regulations, or CMS implementation guidance, with such amendments
taking effect upon thirty (30) Days' written notice to Staff Member/Volunteer ("CDO
notice period"). Staff Member/Volunteer may reject such amendment, by providing
to CDO, during the CDO notice period, thirty (30) Days' written notice of its intent to
reject the amendment ("rejection notice period"). Any such rejection of such
amendment made by CDO for purposes of reflecting changes in applicable law,
regulations, or CMS implementation guidance shall result in the termination of this
Agreement upon expiration of the rejection notice period.
10

d. Compliance with Law. CDO and Staff Member/Volunteer shall comply with any and
all applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable to
the conduct of the activities that are the subject of this Agreement, including but not
limited to, any additional and applicable standards required by statute, and any
regulations or policies implementing or interpreting such statutory provisions
hereafter issued by CMS. In the event of a conflict between the terms of this
Agreement and, any statutory, regulatory, or sub-regulatory guidance released by
CMS, the requirement which constitutes the stricter, higher or more stringent level of
compliance controls.
e. [Placeholder for Governing Law provision]
f [Placeholder for Notices provision]
g. [Placeholder for Severability provision]
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
11

This "Agreement between CDO and Staff Member/Volunteer has been signed by:
FOR CDO:
By:
{Title of person authorized to enter into
agreements on behalf of organization to bind
the organization]
Date:
FOR Staff Member/Volunteer:
Printed Name:
Alveda Danks
Date: {-II
12

MODEL AGREEMENT BETWEEN CERTIFIED APPLICATION COUNSELOR
DESIGNATED ORGANIZATION IN A STATE IN WHICH THE FEDERALLY-
FACILITATED EXCHANGE IS OPERATING AND CERTIFIED APPLICATION
COUNSELOR
THIS AGREEMENT ("Agreement") is entered into between Maricopa County Department
of Public Health, Health Care for the Homeless, an organization that The Centers for
Medicare & Medicaid Services ("CMS"), which manages and oversees the Federally-facilitated
Exchanges ("FFEs"), has designated as a Certified Application Counselor .Designated
Organization in Arizona, a State/States in which an FFE is operating (hereinafter referred to as
"CDO") and isabel May, a staff member or volunteer of the CDO who wishes to be certified by
the CDO to act as a Certified Application Counselor (hereinafter referred to as "Staff
Member/Volunteer") and to perform the duties and meet the standards and requirements of 45
CFR 155.225. The CDO and Staff Member or Volunteer are hereinafter sometimes referred to
as "Party," or, collectively, as the "Parties."
WHEREAS:
1. Pursuant to 45 CFR 155.225(b), CMS may designate an organization to certify its staff
members or volunteers to act as Certified Application Counselors.
2. CMS has designated CDO to certify staff members and volunteers to act as certified
application counselors in an FFE.
3. Pursuant to 45 CFR 155.225(c), CACs are expected to provide the following services to
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or these individuals' legal representative(s) or Authorized
Representative(s):
a. Provide information about the full range of Qualified Health Plan (QHP) options
and Insurance Affordability Programs for which these persons are eligible;
b. Assist with applications for coverage in a QFIP through the FFE and for Insurance
Affordability Programs; and
c. Help to facilitate enrollment in QHPs and Insurance Affordability Programs.
4. The CDO, and the staff members and volunteers that the CDO certifies as CACs, will
need to create, collect, disclose, access, maintain, store, and/or use the Personally
Identifiable Information ("PIP) from CMS, Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) that is necessary to carry out the
Authorized Functions described at III.b below.
5. CDO has determined that it would be beneficial to permit the staff members and
volunteers it certifies as CACs to create, collect, disclose, access, maintain, store, and
1

Employees, and Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s), in order to perform the Authorized Functions described in Section
III.b of this Agreement.
6. 45 CFR 155.225(d)(3) requires all CACs to comply with the Exchange's privacy and
security standards adopted consistent with 45 CFR 155.260, and applicable
authentication and data security standards.
7. CMS, in the administration of the FFEs, has adopted privacy and security standards
concerning personally identifiable information ("PH") and applicable authentication and
data security standards, which are set forth in Appendix A, "Privacy and Security
Standards and Implementation Specifications for Non-Exchange Entities." Compliance
with this Agreement satisfies the requirement under 45 CFR 155.225(d)(3) to comply
with applicable authentication and data security standards.
Now, therefore, in consideration of the promises and covenants herein contained, the adequacy
of which the Parties acknowledge, the Parties agree as follows.
I. DEFINITIONS. Capitalized terms not otherwise specifically defined herein shall have
the meaning set forth in the attached Appendix B, "Definitions," and/or in 45 CFR
155.20, which definitions are hereby incorporated by reference.
II. OBLIGATIONS AND CONDITIONS
a. Staff Member/Volunteer's Obligations and Conditions. To carry out the functions
authorized by 45 CFR 155.225, and as a condition of Staff Member/Volunteer's
certification by CDO, Staff Member/Volunteer agrees to the following:
i. Prior to functioning as a CAC, Staff Member/Volunteer shall do all of the
following:
1. Register with CDO and receive a unique identifying number and a
CAC Certificate, in accordance with CDO's procedures [ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL BY REFERENCE RATHER
THAN CREATE ITS OWN PROCEDURES] as set forth in Section 2
of the CAC User Manual, which is incorporated by reference into this
Agreement Appendix C, "CAC User Manual"];
2. Register for CMS-approved training using Staff Member/Volunteer's
unique CAC identification number and the name that will appear on
both his or her CAC Certificate and Training Certificate;
3. Complete CMS-approved training regarding QHP options, Insurance
Affordability Programs, eligibility, and benefits rules and regulations
2

governing all Insurance Affordability Programs operated in the state,
as implemented in the state;
4. Complete and achieve a passing score on all CMS-approved
certification examinations;
5. Provide proof in the form of his or her printed Training Certificate to
CDO that he or she has fulfilled the training and certification
examination requirements specified in Section Il.b.i.2 and 3; and
6. Execute this Agreement.
ii. Staff Member/Volunteer shall disclose to CDO and to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized
Representative(s) any relationship Staff Member/Volunteer has with QHPs or
Insurance Affordability Programs, or other potential conflicts of interest;
iii. [FOR USE ONLY IF THE CDO DECIDES TO REQUIRE THIS] Staff
Member/Volunteer shall disclose to Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) any relationship
the CDO has with QHPs or Insurance Affordability Programs, or other
potential conflicts of interest, using language supplied by CDO;
iv. Staff Member/Volunteer shall comply with all provisions of this Agreement
and its attachments, all of which are hereby incorporated by reference,
including Appendix A, "Privacy and Security Standards and Implementation
Specifications for Non-Exchange Entities," which was drafted in conformance
with 45 CFR 155.260;
v. Staff Member/Volunteer shall act in the best interests of any Consumer,
Applicant, Qualified Individual, Enrollee, Qualified Employee, or Qualified
Employer that he or she assists;
vi. Staff Member/Volunteer shall, either directly or through an appropriate
referral to a Navigator or non-Navigator assistance personnel authorized under
45 CFR §§ 155.205(d) and (e) or 155.210, or to the Exchange call center
authorized under 45 CFR § 155.205(a), provide information in a manner that
is accessible to individuals with disabilities, as defined by the Americans with
Disabilities Act, as amended, 42 USC § 12101, et seq. and section 504 of the
Rehabilitation Act, as amended, 29 USC § 794;
vii. Staff Member/Volunteer shall provide information to Consumers, Applicants,
Qualified Individuals, Enrollees, Qualified Employees, and Qualified
Employers, and/or their legal representative(s) or Authorized

Representative(s) about the full range of QHP options and Insurance
Affordability Programs for which they are eligible;
viii. Staff Member/Volunteer shall assist Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or
their legal representative(s) or Authorized Representative(s) in applying for
coverage in a QHP through the Marketplace and for Insurance Affordability
Programs;
ix. Staff Member/Volunteer shall help to facilitate enrollment of eligible
Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, and Qualified Employers in QHPs and Insurance Affordability
Programs;
x. Staff Member/ Volunteer shall follow CDO's established procedures[ADD
FOLLOWING LANGUAGE ONLY IF THE CDO DECIDES TO
INCORPORATE USER MANUAL AND SOPS BY REFERENCE RATHER
THAN DEVELOP OTHER PROCEDURES] as set forth in Appendix C,
"CAC User Manual," and Appendix D, "CAC Standard Operating Procedures
(SOPs)," which are incorporated by reference into this Agreement], to:
Prominently display to Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their
legal representative(s) or Authorized Representative(s) the CAC
Certificate provided by CDO evidencing the individual's certification
as a CAC each time Staff Member/Volunteer assists any of these
persons;
2. Inform Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), of the functions and
responsibilities of CACs. Staff Member/Volunteer may use the model
form provided by CMS and appended hereto and referred to as
Appendix E to fulfill this requirement;
3. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any PIT of Consumers, Applicants, Qualified
Individuals, Enrollees, Qualified Employees, Qualified Employers,
and/or these individual's legal representatives(s) or Authorized
Representative(s) obtain the authorization required by 45 CFR
155.225(f) and section III.d of this Agreement (hereinafter referred to
as "authorization") to create, collect, disclose, access, maintain, store,
and use P11 of such person(s) to carry out the Authorized Functions
listed at Section III.b of this Agreement. This authorization may be
obtained either directly from the Consumer, Applicant, Qualified
Individual, Enrollee, Qualified Employee, and/or Qualified Employer,
4

or through such person(s)' legal representative(s) or Authorized
Representative(s). Staff Member/Volunteer may use the model form
provided by CMS and appended hereto and referred to as Appendix E
to fulfill this requirement. This authorization is separate and distinct
both from any authorization obtained pursuant to section III.g of this
agreement and from the informed consent referenced in Appendix A at
3(a);
4. Maintain a record of the authorization provided under Section II.a.x.3;
5. Permit the Consumer, Applicant, Qualified Individual, Enrollee,
Qualified Employee, and Qualified Employer, and/or their legal
representative(s) or Authorized Representative(s) to revoke the
authorization described in Section Il.a.x.3. at any time;
6. Provide his or her unique CAC identification number to any
Consumer, Applicant, Qualified Individual, Enrollee, Qualified
Employee, and Qualified Employer, and/or these individuals' legal
representative(s) or Authorized Representative(s) assisted by Staff
Member/Volunteer, and include his or her unique CAC identification
number on any application that is partially or fully completed in
connection with Staff Member/Volunteer's assistance for that
individual;
xi. Staff Member/Volunteer shall not impose any charge on any Consumers,
Applicants, Qualified Individuals, Enrollees, Qualified Employees, and
Qualified Employers, and/or their legal representative(s) or Authorized
Representative(s) for application or other assistance related to the Exchange;
xii. Staff Member/Volunteer shall not sell or otherwise transfer information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s) to any person or entity
other than such actions as are specifically permitted by this Agreement;
xiii. Staff Member/Volunteer shall not collect or otherwise maintain information
provided by Consumers, Applicants, Qualified Individuals, Enrollees,
Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), except as specifically
provided for in this Agreement;
xiv. Upon termination or nonrenewal of Staff Member/Volunteer's agreement with
CDO, Staff Member/Volunteer shall immediately cease holding himself or
herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these

individuals' legal representative(s) or Authorized Representative(s), and
immediately cease providing CAC services to the public; and
xv. As evidenced by my signature hereon, I hereby agree to provide the duties and
services described herein without compensation of any kind (other than the
wages I may nonetheless earn as an employee of CDO for work performed on
behalf of my employer), and hereby waive my rights to any fee, remuneration
or compensation to which I might somehow be entitled to receive from the
Government of the United States of America under applicable law.
III. OBLIGATIONS RELATED TO THE PRIVACY AND SECURITY OF PERSONALLY
IDENTIFIABLE INFORMATION.
a. Staff Member/Volunteer hereby acknowledges and agrees to accept and abide by the
standards and implementation specifications set forth below and in Appendix A,
"Privacy and Security Standards and Implementation Specifications for Non-
Exchange Entities," which is incorporated by reference in this Agreement, when
engaging in any activity as a CAC pursuant to 45 CFR 155.225. Staff Member/
Volunteer is thereby bound to strictly adhere to the privacy and security standards,
and to ensure that any Workforce it may have that creates, collects, accesses, stores,
maintains, discloses, or uses PII, is contractually bound to strictly adhere to the
equivalent standards and implementation specifications, so as to ensure the efficient
operation of the FFE.
b. Authorized Functions. Staff Member/ Volunteer may create, collect, disclose, access,
maintain, store, and use PIT of Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, or these individuals' legal
representative(s) or Authorized Representative(s), in order to:
1. Provide information about the full range of QHP options and Insurance
Affordability Programs for which these persons are eligible;
2. Assist these persons with applications for coverage in a QHP through the FFE and
for Insurance Affordability Programs;
3. Help to facilitate the enrollment of these persons in QHPs and Insurance
Affordability Programs; and
4. Perform other functions authorized under 45 CFR 155.225, including functions
substantially similar to those enumerated above, and such other functions that
may be approved by CDO in writing from time to time, but only if CMS has
expressly permitted CDO to carry out those functions.
c. PIT Received. Subject to the terms and conditions of this Agreement and applicable
laws, in performing the tasks contemplated under this Agreement, Staff Member/
Volunteer may create, collect, disclose, access, maintain, store, and use the following
6

data and PII from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or these individuals' legal representative(s) or
Authorized Representative(s):
APTC percentage and amount applied
Auto disenrollment information
Applicant Name
Applicant Address
Applicant Birthdate
Applicant Telephone number
Applicant Email
Applicant spoken and written language preference
Applicant Medicaid Eligibility indicator, start and end dates
Applicant Children's Health Insurance Program eligibility indicator, Start and end
dates
Applicant QHP eligibility indicator, start and end dates
Applicant APTC percentage and amount applied eligibility indicator, start and end
dates
Applicant household income
Applicant Maximum APTC amount
Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates
Applicant CSR level
Applicant QHP eligibility status change
Applicant APTC eligibility status change
Applicant CSR eligibility status change
Applicant Initial or Annual Open Enrollment Indicator, start and end dates
Applicant Special Enrollment Period eligibility indicator and reason code
Contact Name
Contact Address
Contact Birthdate
Contact Telephone number
Contact Email
Contact spoken and written language preference
Enrollment group history (past six months)
Enrollment type period
FFE Applicant ID
FFE Member ID
Issuer Member ID
Net premium amount
Pregnancy indicator
Premium Amount, start and end dates
Special enrollment period reason
Subscriber Indicator and relationship to subscriber
Social Security Number
Tobacco use indicator and last date of tobacco
7

d. Authorization. Prior to creating, collecting, disclosing, accessing, maintaining,
storing, or using any P11 from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals'
legal representative(s) or Authorized Representative(s), Staff Member/Volunteer will
obtain the authorization required under Section II.a.x.3 of this Agreement to create,
collect, disclose, access, maintain, use, or store their PII to carry out the Authorized
Functions listed at Section III.b of this Agreement, and will permit the authorization
to be revoked at any time. Staff Member/Volunteer may use the model form provided
by CMS and appended hereto and referred to as Appendix E to fulfill this
requirement. This authorization is separate and distinct from any authorization
obtained pursuant to section III.g of this agreement and the informed consent
referenced in Appendix A at 3(a). The CDO should ensure that a record of the
authorization provided is maintained in a manner consistent with the privacy and
security standards set forth in Appendix A.
e. Collection of PIT. PII collected from Consumers, Applicants, Qualified Individuals,
Enrollees, Qualified Employees, and Qualified Employers, and/or their legal
representative(s) or Authorized Representative(s), may be used only for the
Authorized Functions specified in Section III.b of this Agreement. Such information
may not be reused for any other purpose.
f. Storing PII. Other than documentation related to the authorization required by Section
III.d above, Staff Member/Volunteer is not expected or required to maintain or store
any of the above listed PIT as a result of carrying out the Authorized Functions
specified in Section III.b above. To the extent that Staff Member/ Volunteer does
maintain or store PIT, such as documentation related to the authorization required by
Section III.d, he or she must agree to comply with all provisions of this Agreement
and Appendix A that apply to the maintenance or storage of PII.
g. Collection and Use of Information Provided Under Other Authorities. This
Agreement does not preclude Staff Member/Volunteer from separately collecting
information from Consumers, Applicants, Qualified Individuals, Enrollees, Qualified
Employees, Qualified Employers, or their legal representative(s) or Authorized
Representative(s), for a non-FFE purpose, and using, reusing, and disclosing such
non-FFE information obtained separately as permitted by applicable law and/or other
applicable authorities. Such information must be separately collected and stored from
any PII collected in accordance with this Agreement. Any authorization for collection
and use of PIT under this provision is separate and distinct from the authorization
obtained pursuant to Section III.d above and II.a.x.3, and should be obtained and
maintained separately from that authorization.
h. Ability of Consumer to Limit Collection and Use. Staff Member/Volunteer agrees to
allow the Consumer, Applicant, Qualified Individual, Enrollee, Qualified Employee,
Qualified Employer, directly or through their legal representative(s) or Authorized
Representative(s), to limit Staff Member/Volunteer's creation, collection, use,
maintenance, storage, and disclosure of their PII to the sole purpose of obtaining Staff
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Member/Volunteer's assistance for FFE purposes, and for performing Authorized
Functions specified in Section Mb of this Agreement.
IV. EFFECTIVE DATE; TERM AND RENEWAL.
a. Effective Date and Term. This Agreement becomes effective on the date the last of
the two Parties signs this Agreement and ends one year from the effective date.
b. Renewal. This Agreement will automatically renew for subsequent and consecutive
one (1) year periods upon the expiration of this Agreement, unless:
i. CDO is no longer designated by CMS; or
CDO, in its sole and absolute discretion, notifies Staff Member/Volunteer
with 30 Days' advance written notice that it has determined that the
Agreement will not be renewed. Such notice will specify whether and under
what conditions CDO will renew the Agreement; or
CDO terminates the Agreement pursuant to Section V of this Agreement.
V Termination
a. Termination without Cause. Either Party may terminate this Agreement without
cause upon thirty (30) Days' prior written notice to the other Party.
b. Termination with Cause. This Agreement shall terminate immediately when Staff
Member/Volunteer no longer holds a position as a staff member or volunteer at CDO,
or when CDO withdraws Staff Member/Volunteer's certification as a CAC, or when
CMS has withdrawn CDO's designation as a CDO. CDO may terminate this
Agreement for cause as soon as possible, but in no event later than twenty (20) Days
after the triggering event (identification or notification of noncompliance) if CDO
learns or is notified by CMS that Staff Member/Volunteer has failed to comply with
the terms and conditions of this Agreement or with any applicable requirements of 45
CFR 155.225, unless Staff Member/Volunteer commences curing such breach(es)
within such 20-Day period to the reasonable satisfaction CDO, and thereafter
diligently implements such cure to completion. The 20-Day notice from CDO shall
contain a description of the material breach, whereupon Staff Member/Volunteer
shall have seven (7) Days from the date of the notice in which to propose a plan and a
time frame to cure the material breach, which plan and time frame may be rejected,
approved or amended in CDO' s sole but reasonable discretion. Notwithstanding the
foregoing, Staff Member /Volunteer shall be considered in "Habitual Default" of this
Agreement in the event that it has been served with a 20-Day notice under this
subsection more than three (3) times in any calendar year, whereupon CDO may, in
its sole discretion, immediately thereafter terminate this Agreement upon notice to
Staff Member/Volunteer without any further opportunity to cure or propose cure.
c. Consequences of Termination or Nonrenewal. If this Agreement is not renewed
pursuant to Section IV.b or is terminated pursuant to Sections V.a or V.b of this
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Agreement, Staff Member/Volunteer's certification as a CAC is automatically
withdrawn. If that occurs Staff Member/Volunteer must immediately cease holding
himself or herself out as a CAC to any Consumer, Applicant, Qualified Individual,
Enrollee, Qualified Employee, and Qualified Employer, and/or these individuals'
legal representative(s) or Authorized Representative(s), and must immediately cease
providing CAC services to the public.
VI. DESTRUCTION OF PIT. Staff Member/Volunteer covenants and agrees to destroy all
PIT in his or her possession at the end of the record retention period required under
Appendix A. If, upon the termination or expiration of this Agreement Staff Member/
Volunteer has in his or her possession PII for which no retention period is specified in
Appendix A, such P11 shall be destroyed within thirty (30) Days of the termination or
expiration of this Agreement. Staff Member/Volunteer's duty to protect and maintain the
privacy and security of PIT, as provided for in Appendix A of this Agreement, shall
continue in full force and effect until such PIT is destroyed and shall survive the
termination or expiration of this Agreement.
VII. GENERAL PROVISIONS.
a. Assignment and Delegation. Staff Member/Volunteer shall not assign its rights or
delegate its performance under this Agreement. CDO shall not assign its rights or
delegate its performance under this Agreement without the express prior written
consent of CMS.
b. Disclaimer. Neither this Agreement nor the activities of the Parties contemplated
under this Agreement shall be deemed or construed to create in any way any
partnership, joint venture or agency relationship between either or 'both of the Parties
hereto on one hand and the United States of America (or any of its agencies or
departments) on the other. Neither CDO nor Staff Member/Volunteer is, nor shall
either CDO or Staff Member/Volunteer hold itself out to be, vested with any power,,
authority or right to act on behalf of the United States of America in any manner as an
agent or representative thereof, or to bind the United States in any manner or fashion.
c. Amendments. CDO may amend this Agreement fur purposes of reflecting changes in
applicable law, regulations, or CMS implementation guidance, with such amendments
taking effect upon thirty (30) Days' written notice to Staff Member/Volunteer ("CDO
notice period"). Staff Member/Volunteer may reject such amendment, by providing
to CDO, during the CDO notice period, thirty (30) Days' written notice of its intent to
reject the amendment ("rejection notice period"). Any such rejection of such
amendment made by CDO for purposes of reflecting changes in applicable law,
regulations, or CMS implementation guidance shall result in the termination of this
Agreement upon expiration of the rejection notice period.
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d. Compliance with Law. CDO and Staff Member/Volunteer shall comply with any and
all applicable laws, statutes, regulations or ordinances of the United States of
America, and any Federal Government agency, board or court, that are applicable to
the conduct of the activities that are the subject of this Agreement, including but not
limited to, any additional and applicable standards required by statute, and any
regulations or policies implementing or interpreting such statutory provisions
hereafter issued by CMS. In the event of a conflict between the terms of this
Agreement and, any statutory, regulatory, or sub-regulatory guidance released by
CMS, the requirement which constitutes the stricter, higher or more stringent level of
compliance controls.
e. [Placeholder for Governing Law provision
[Placeholder for Notices provision]
g. [Placeholder for Severability provision]
[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]
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This "Agreement between CDO and Staff Member/Volunteer has been signed by:
FOR CDO:
By:
[Title of person authorized to enter into
agreements on behalf of organization to bind
the organization]
Date:
FOR Staff Member/Volunteer:
Printed Name:
Isabel May
Date: 9 //
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