Plan Year 2027 Broker Enrollment Event Request Form

Enrollment events will only take place during the Open Enrollment period. The event request form must be submitted by December 1, 2026 and no less than 10 business days prior to the enrollment event. If the event is approved you will receive a notification email from BeWell.

Hosting a BeWell event requires the following:

Brokers need to be certified for two consecutive years, in both the current and upcoming plan years.
Brokers need to have completed a minimum of 5 QHP enrollments through their NMHIX broker portal.
Brokers will be responsible for reporting event outcomes to BeWell within 7 days of the event. If event outcomes are not reported it may result in future events being cancelled or not approved.
Brokers must have at least one additional broker or support staff available at the event to provide consumer assistance.

Please submit any questions to partners@nmhix.com

Question Title

1. Please provide the contact information (Required.)

Full Name of Primary Contact

Email Address of Primary Contact

Phone Number of Primary Contact

Full Name of Support Staff

Email Address of Support Staff

Phone Number of Support Staff

Question Title

2. Event Date and Start Time

Event should not be longer than 4 hours
(Required.)

Start time

Date

Time

AM/PM

End time

Date

Time

AM/PM

Question Title

3. Is this a reoccurring event? (Required.)

Yes

If yes, please specify the end date or how long it will continue Example: Weekly, bi-weekly and end date

Question Title

4. Event Address and Location Name--in addition to the address, please provide the name of the location if it has a recognizable or posted name Example: ABC Agency, XYZ Community Center (Required.)

Question Title

5. Is the location visible from the street? Will there be posted signage to assist consumers in finding the location? (Required.)

Question Title

6. Does the location have a private space for meeting with consumer? Example: Tables at least 6 feet apart (Required.)

Yes

Question Title

7. Is this an outdoor event? (Required.)

Yes

Question Title

8. Will there be a Spanish speaking broker available? (Required.)

Yes

Question Title

9. How will you be referring Medicaid consumers? Select all that apply. (Required.)

Presumptive Eligibility Determiner

Income Support Division Office

Health Care Authority Call Center

Other (please specify)

Question Title

10. How do you plan to market your event? Select all that apply. (Required.)

Instagram

Facebook

Nextdoor

Paper Flyers

Other Ways You Plan to Market Your Event

Plan Year 2027 Broker Enrollment Event Request Form

Question Title

* 1. Please provide the contact information (Required.)

Question Title

* 2. Event Date and Start TimeEvent should not be longer than 4 hours (Required.)

Question Title

* 3. Is this a reoccurring event? (Required.)

Question Title

* 4. Event Address and Location Name--in addition to the address, please provide the name of the location if it has a recognizable or posted name Example: ABC Agency, XYZ Community Center (Required.)

Question Title

* 5. Is the location visible from the street? Will there be posted signage to assist consumers in finding the location? (Required.)

Question Title

* 6. Does the location have a private space for meeting with consumer? Example: Tables at least 6 feet apart (Required.)

Question Title

* 7. Is this an outdoor event? (Required.)

Question Title

* 8. Will there be a Spanish speaking broker available? (Required.)

Question Title

* 9. How will you be referring Medicaid consumers? Select all that apply. (Required.)

Question Title

* 10. How do you plan to market your event? Select all that apply. (Required.)

Question Title

* 11. What support will you be needing from BeWell for this event?

1. Please provide the contact information (Required.)

2. Event Date and Start Time

Event should not be longer than 4 hours
(Required.)

3. Is this a reoccurring event? (Required.)

4. Event Address and Location Name--in addition to the address, please provide the name of the location if it has a recognizable or posted name Example: ABC Agency, XYZ Community Center (Required.)

5. Is the location visible from the street? Will there be posted signage to assist consumers in finding the location? (Required.)

6. Does the location have a private space for meeting with consumer? Example: Tables at least 6 feet apart (Required.)

7. Is this an outdoor event? (Required.)

8. Will there be a Spanish speaking broker available? (Required.)

9. How will you be referring Medicaid consumers? Select all that apply. (Required.)

10. How do you plan to market your event? Select all that apply. (Required.)

11. What support will you be needing from BeWell for this event?