Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 201407-0938-016 · OMB 0938-1221.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1221 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10488 Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
CMS-10488 Vendor Form ESS Survey Vendor Participation Form.pdf	Form and Instruction
CMS-10488 English Adult QHP Enrollee Survey CMS-10488 - English Adult QHP Enrollee Survey for Field Test_clean.docx	Form and Instruction
CMS-10488 Spanish - Qualified Health Plan Enrollee Experience Surv Spanish Adult QHP Enrollee Survey for Field Test_7-31-14_new screeners_clean_CMS.docx	Form and Instruction
CMS-10488 Chinese - Qualified Health Plan Enrollee Experience Chinese Adult QHP Enrollee Survey for Field Test_7-31-14_new screeners_clean_CMS.docx	Form and Instruction

IC Title:

Adult Qualified Health Plan Enrollee Experience Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Spanish - Qualified Health Plan Enrollee Experience Survey	Spanish Adult QHP Enrollee Survey for Field Test_7-31-14_new screeners_clean_CMS.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Chinese - Qualified Health Plan Enrollee Experience	Chinese Adult QHP Enrollee Survey for Field Test_7-31-14_new screeners_clean_CMS.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Vendor Form	ESS Survey Vendor Participation Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	English Adult QHP Enrollee Survey	CMS-10488 - English Adult QHP Enrollee Survey for Field Test_clean.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 604,240

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	604,240	604,240
Annual IC Time Burden (Hours)	271,930	271,930
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.