Adult Qualified Health Plan Enrollee Experience Survey

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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 QHP Enrollee Survey (Beta Test) - Chinese Chinese Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx Form and Instruction
CMS-10488 QHP Enrollee Survey (Beta Test) - English English Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx Form and Instruction
CMS-10488 QHP Enrollee Survey (Beta Test) - Spanish Spanish Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx Form and Instruction

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10488	Vendor Form	ESS Survey Vendor Participation Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Enrollee Survey (Beta Test) - Chinese	Chinese Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Enrollee Survey (Beta Test) - English	English Adult QHP Enrollee Survey for Beta Test_9-9-14_Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Enrollee Survey (Beta Test) - Spanish	Spanish Adult QHP Enrollee Survey for Beta Test_9-9-14_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: 180,010	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	180,010	-424,230	604,240
Annual IC Time Burden (Hours)	57,610	-214,320	271,930
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.