Information Collection

Health Insurance Marketplace Consumer Experience Surveys: Enrollee Satisfaction Survey and Marketplace Survey

IC 209213 under ICR 201311-0938-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10488 Health Insurance Marketplace Consumer Experience Surveys: Enrollee Satisfaction Survey and Marketplace Survey	Form and Instruction
CMS-10488 Chinese Cover Letter CMS- 10488 - Cover Letters_Chinese_101413_clean.docx	Form and Instruction
CMS-10488 English/Spanish CMS-10488 - Cover Letters_English and Spanish_ 9-30-13 (clean).doc	Form and Instruction
CMS-10488 Vendor Participation Form CMS-10488 - Vendor Participation Form_clean.docx	Form and Instruction
CMS-10488 Chinese Marketplace Survey CMS-10488 - Chinese Marketplace Survey_Sept30_clean.docx	Form and Instruction
CMS-10488 English Marketplace Survey CMS-10488 - English Marketplace Survey_Sept_30_2013_clean.docx	Form and Instruction
CMS-10488 Spanish Marketplace Survey CMS-10488 - Spanish Marketplace Survey_ Sept 30_clean.docx	Form and Instruction
CMS-10488 Chinese QHP Enrollee Survey CMS-10488 - Chinese QHP Enrollee Survey_Sept 30_clean.docx	Form and Instruction
CMS-10488 English QHP Enrollee Survey CMS-10488 - English QHP Enrollee Survey_Sept_30_2013_clean.docx	Form and Instruction
CMS-10488 Spanish QHP Enrollee Survey CMS-10488 - Spanish QHP Enrollee Survey_Sept 30_Clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 156.200(b)(5) 45 CFR 155.200(d)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10488	Chinese Cover Letter	CMS- 10488 - Cover Letters_Chinese_101413_clean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10488	English/Spanish	CMS-10488 - Cover Letters_English and Spanish_ 9-30-13 (clean).doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Vendor Participation Form	CMS-10488 - Vendor Participation Form_clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Chinese Marketplace Survey	CMS-10488 - Chinese Marketplace Survey_Sept30_clean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10488	English Marketplace Survey	CMS-10488 - English Marketplace Survey_Sept_30_2013_clean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10488	Spanish Marketplace Survey	CMS-10488 - Spanish Marketplace Survey_ Sept 30_clean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10488	Chinese QHP Enrollee Survey	CMS-10488 - Chinese QHP Enrollee Survey_Sept 30_clean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10488	English QHP Enrollee Survey	CMS-10488 - English QHP Enrollee Survey_Sept_30_2013_clean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10488	Spanish QHP Enrollee Survey	CMS-10488 - Spanish QHP Enrollee Survey_Sept 30_Clean.docx	No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 755,043

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	755,043	755,043
Annual IC Time Burden (Hours)	100,708	100,708
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.