Form CMS-10488 Vendor Form

Qualified Health Plan Survey

2015 ENROLLEE SATISFACTION SURVEY VENDOR
PARTICIPATION FORM
A survey vendor must meet all of the Minimum Business Requirements in order to apply to
administer the Qualified Health Plan (QHP) Survey on behalf of QHP issuers.
This Participation Form is to be completed by organizations requesting approval to administer
the 2015 QHP Survey on behalf of QHP issuers. Approval into the 2015 survey vendor program
is contingent on successful completion of 2015 Survey Vendor Training (scheduled for Month,
Day, Year).
ALL SURVEY VENDOR APPLICATIONS AND MATERIALS ARE DUE BY: [due date]
PARTICIPATION STATUS

DATE SUBMITTED

☐ New Participation Form
☐ Appeal of Participation Denial

I.

General Information

This section is to be completed with general information for participation.
1. Organization Name
2. Organization Mailing Address
3. Telephone Number
4. Website
5. Number of Years in Business
(Date Company Founded)
6. Number of Years Conducting Surveys
7. Primary Contact Person
(First, Middle, Last Name; Title; Degree)
8. Primary Contact Mailing Address
9. Primary Contact Telephone Number
10. Primary Contact E-mail Address

II.

QHP Survey Minimum Business Requirements

Survey vendors must meet the following Minimum Business Requirements. Please check “Yes”
or “No” for each item below to indicate that the organization has read and meets the following
Minimum Business Requirements.

1. Relevant Survey Experience
Number of Years in Business

☐ Yes

☐ No

Survey vendor has conducted large scale patient experience surveys using
mixed mode (mail with telephone follow-up) survey administration for a
minimum of two years.

☐ Yes

☐ No

Survey vendor has prior experience administering patient experience surveys
for vulnerable populations.

☐ Yes

☐ No

Survey vendor has prior experience submitting patient experience survey data
to an external third-party organization.

☐ Yes

☐ No

Survey vendor has prior experience employing a statistical sampling process
in the conduct of previously or currently conducted surveys.

☐ Yes

☐ No

Survey vendor has been in business for a minimum of three years.
Survey Experience

List the five most recent standardized health care patient experience surveys conducted as an
organization:
Survey

Average
Sample
Size Per
Data
Collection
Period

Data
Collection
Period
Start and
End Dates

Number of
Contracted
Clients

Mode of Survey
Administration
Mixed Mode,
Mail Only,
Telephone Only

Survey
Language(s)

Number of
Years
Administering
Survey

Experience with Survey Administration in Multiple Languages
Survey vendor has prior experience administering mail and telephone
surveys in Spanish.

☐ Yes

☐ No

☐ Yes

☐ No

Optional:
Survey vendor(s) will have the option of conducting the 2015 survey in
Chinese (Mandarin) and should have prior experience with Chinese
language survey administration if choosing to administer Chinese language
surveys.
Survey vendor has prior experience administering mail and telephone
surveys in Chinese (Mandarin).

Explanation
Please explain any “No” responses to the above relevant survey experience requirements.
Indicate the requirement(s) to which your explanation applies:

2. Organizational Survey Capacity
Capacity to Handle Estimated Workload
Survey vendor has sufficient physical and personnel resources to administer
large-scale outgoing and incoming mail surveys and perform computerassisted telephone interview (CATI) system telephone interviews during the
survey fielding time period (estimated first quarter of calendar year). Survey
vendor must adhere to requirements specified in Qualified Health Plan
Survey Quality Assurance Guidelines and Technical Specifications.

☐ Yes

☐ No

Personnel
Survey vendor has a designated Project Manager overseeing all survey
operations with at least two years of experience in overseeing all functional
aspects of survey operations including mail, telephone, data file preparation
and data security. Strong background in survey research and methodology
and previous experience using specified modes of administration, as
evidenced by CV. Experience with another organization does not qualify as
meeting minimum requirements.

☐ Yes

☐ No

Survey vendor has designated Sampling Manager, who is directly employed
by survey vendor, with sample frame development and sample selection
experience.

☐ Yes

☐ No

Survey vendor has designated Telephone Survey Supervisor with previous
experience managing national scale telephone interviewing projects.

☐ Yes

☐ No

Survey vendor has designated Mail Supervisor has previous experience
managing large-scale mail survey projects.

☐ Yes

☐ No

Survey vendor has designated Information System staff responsible for data
submission (programmer) who are directly employed by survey vendor (i.e.,
not a subcontractor) and has previous experience preparing and submitting
data files in XML format to external third-party organization within the past
two years.

☐ Yes

☐ No

Survey vendor has appropriate, in terms of sufficiency and experience,
organizational back-up staff for coverage of key staff.

☐ Yes

☐ No

Survey vendor and its designated subcontractors (if applicable), conducts
business operations from a commercial physical plant, which is owned or
leased by the organization.

☐ Yes

☐ No

Survey vendor will conduct all survey-related work, including telephone
interviewing, at the survey vendor’s or approved subcontractor’s official
commercial business location. Telephone interviews will not be conducted
from an interviewer’s residence and incoming paper surveys will not be
removed from a survey vendor’s, or their designated subcontractor’s, official
business location.

☐ Yes

☐ No

Survey vendor has the capacity for reproducing and mailing questionnaires,
cover letters and postcards in-house or in accordance with requirements
outlined in “Approved Use of Subcontractors.”

☐ Yes

☐ No

Survey vendor has capacity for programming electronic telephone
interviewing systems in accordance with specifications provided and
conducting telephone interviews using a CATI system in-house or in
accordance with requirements outlined in “Approved Use of Subcontractors.”

☐ Yes

☐ No

System Resources

Survey vendor has capacity to handle concurrent survey projects while
maintaining high quality survey data and high response rates.
Survey vendor will prepare for and accommodate on-site visits from CMS or
CMS-contractor personnel for quality oversight purposes.
Survey vendor will track fielded surveys using an electronic survey
management system through each stage of the protocol through the use of a
unique individual identifier ID and interim disposition codes.

☐ Yes

☐ No

☐ Yes

☐ No

☐ Yes

☐ No

Survey vendor will provide regular progress reports to client QHP issuers,
within guidelines specified by CMS.

☐ Yes

☐ No

Survey vendor will provide a secure work environment for receiving,
processing and storing hardcopy and electronic versions of questionnaires and
sample files that protects the confidentiality of survey response data and
personal identifying information.

☐ Yes

☐ No

Survey vendor has experience preparing and submitting data via secure
methods (HIPAA compliant).

☐ Yes

☐ No

Survey vendor will comply with all quality oversight requirements described
in the Qualified Health Plan Survey Quality Assurance Guidelines and
Technical Specifications, including submitting sample mail materials for
review prior to mass production.

☐ Yes

☐ No

Survey vendor will comply with all requirements described in the Qualified
Health Plan Survey Quality Assurance Guidelines and Technical
Specifications, including submitting telephone script and screen shots for
review prior to initiation of telephone interviewing and monitoring at least 10
percent of all telephone interviews conducted by survey vendor or telephone
subcontractor interviewers.

☐ Yes

☐ No

Survey vendor will provide written evidence of their survey administration
processes for collecting and accurately processing survey data through all
phases of survey administration in a Quality Assurance Plan

☐ Yes

☐ No

Survey vendor has prior experience identifying and contacting nonrespondents for follow-up.

☐ Yes

☐ No

Survey vendor will adhere to survey administration timeline.

☐ Yes

☐ No

Survey vendor has experience using commercial software/resources to ensure
that addresses and telephone numbers are updated and correct for all sampled
enrollees.

☐ Yes

☐ No

Sampling Experience
Survey vendor has consistent experience in the two most recent years
selecting a sample based on specific eligibility criteria. Must document
statistical approach to drawing a sample. Must demonstrate ability to work
with individual QHPs to electronically obtain sample frame for sampling.

☐ Yes

☐ No

Survey vendor has the capability to scan or key enter data according to
standard protocols.

☐ Yes

☐ No

Survey vendor will follow all data cleaning and submission rules as specified
in the Qualified Health Plan Survey Quality Assurance Guidelines and
Technical Specifications, including verifying data are de-identified and
contain no duplicate cases.

☐ Yes

☐ No

Survey vendor has the capability to submit data electronically in specified
format. Data files may require encryption for transmission in accordance with
required specifications (HIPAA compliant).

☐ Yes

☐ No

Survey vendor will execute business associate agreements with QHPs and
receive annual authorization from QHPs to collect data on their behalf and
submit to CMS.

☐ Yes

☐ No

Survey vendor will work with the Project Team to resolve data and data file
submission problems.

☐ Yes

☐ No

Data Submission

Data Security
Survey vendor will store returned paper questionnaires (if required) in a secure
and environmentally safe location, either onsite or using an offsite contractor,
and has established electronic security procedures related to access levels,
passwords and firewalls.

☐ Yes

☐ No

Survey vendor will perform data back-up and offsite redundancy procedures
that adequately safeguard system data.

☐ Yes

☐ No

Survey vendor has established procedures for identifying and reporting
breaches of confidential data.

☐ Yes

☐ No

Data Retention
Survey vendor will retain all data files for a minimum of three years.

☐ Yes

☐ No

☐ Yes

☐ No

☐ Yes

☐ No

Confidentiality
Survey vendor will store data files (paper or electronic) securely and
confidentially in accordance with specified requirements. Survey vendor must
ensure confidentiality of sampled individuals is protected during each phase of
the survey process. Survey vendor must obtain signed confidentiality
agreements from staff and subcontractors.
Technical Assistance/Customer Support
Survey vendor has the capacity to establish either in-house, or in accordance
with requirements outlined in “Approved Use of Subcontractors,” toll-free
customer support telephone lines with a live operator during regular business
hours to accommodate both Spanish and English inquiries starting at the
beginning of the survey fielding period and continuing through the duration of
survey fielding. If administering the survey in Chinese (Mandarin),
accommodate telephone inquiries from Chinese-speaking survey participants.

Explanation
Please explain any “No” responses to the above relevant survey experience requirements.
Indicate the requirement(s) to which your explanation applies:

3. Quality Control Procedures
Demonstrated Quality Control Procedures
Survey vendor has the capacity to establish and document quality control
procedures for all phases of survey implementation: internal staff training;
printing, mailing and recording receipt of surveys; telephone administration of
survey (electronic telephone interviewing system); scanning, coding, and
cleaning of survey data; preparing final data files for submission; and all other
functions and processes that affect the administration of the survey as specified
in the Qualified Health Plan Survey Quality Assurance Guidelines and
Technical Specifications.

☐ Yes

☐ No

Explanation
Please explain any “No” responses to the above relevant survey experience requirements.
Indicate the requirement(s) to which your explanation applies:

III.

List of Key Project Staff

Name

1.
2.
3.

Role

Number of
Years with
Organization

E-mail

Telephone

4.
5.

IV.

Subcontractors

Check here if you do not plan to use subcontractors for the QHP survey
administration.

Subcontractor Name(s) and Experience
1. Organization Name
2. Mailing Address
3. Telephone Number
4. Number of Years in Business
5. Number of Years Subcontractor Has
Worked with Your Organization
6. Survey Administration Role
7. Experience Related to Survey
Administration Role, including names of
projects on which subcontractor has
contributed.

1. Organization Name
2. Mailing Address
3. Telephone Number
4. Number of Years in Business
5. Number of Years Subcontractor Has
Worked with Your Organization
6. Survey Administration Role
7. Experience Related to Survey
Administration Role, including names of
projects on which subcontractor has
contributed.

☐

1. Organization Name
2. Mailing Address
3. Telephone Number
4. Number of Years in Business
5. Number of Years Subcontractor Has
Worked with Your Organization
6. Survey Administration Role
7. Experience Related to Survey
Administration Role, including names of
projects on which subcontractor has
contributed.

1. Organization Name
2. Mailing Address
3. Telephone Number
4. Number of Years in Business
5. Number of Years Subcontractor Has
Worked with Your Organization
6. Survey Administration Role
7. Experience Related to Survey
Administration Role, including names of
projects on which subcontractor has
contributed.

V.

Curriculum Vitae (CV) and References

Please submit a CV for all identified key project staff, both the survey vendor and
subcontractor(s) along with no more than three references for the survey vendor via the project
mailbox at [e-mail address].

VI.

Participation Rules

Any survey vendor organization participating in the QHP Survey vendor program must adhere to
the following Participation Rules. To be eligible, the organization must:
1. Participate in a teleconference call with the Project Team (as determined by CMS) to discuss
relevant survey experience, organizational survey capability and capacity, quality control
procedures, and role of subcontractors (if applicable).
2. Submit an interim survey data file to CMS (as determined by CMS).
3. Participate in and successfully complete QHP Survey Vendor Training and all subsequent
survey vendor update trainings. At a minimum, the organization’s Project Manager,
Telephone Survey Supervisor and Sampling Manager must attend training as representatives
of the organization. It is strongly recommended that the Project Director and any additional
key staff responsible for programming, data coding and file preparation also attend training.
All key personnel subcontractor staff must attend survey vendor training.
4. Review and follow the Qualified Health Plan Survey Quality Assurance Guidelines and
Technical Specifications and any policy updates.
5. Attest to the accuracy of the organization’s data collection (as determined by CMS);
following guidelines set forth in the most current version of the Qualified Health Plan Survey
Quality Assurance Guidelines and Technical Specifications.
6. Develop and submit a survey vendor Quality Assurance Plan (QAP) by due date. In addition,
submit materials relevant to the survey administration (as determined by CMS), including
mailing materials (e.g., cover letters and questionnaires) and telephone scripts.
7. Participate and cooperate (including subcontractors) in all oversight activities conducted by
the Project Team.
8. Within 24 months of receiving its approved survey vendor status, survey vendor must
successfully field the QHP Survey for at least one client.
9. Submit data on time according to CMS-specified deadlines. No late submissions will be
allowed.
10. Acknowledge that CMS may, at its sole discretion, terminate, discontinue or not renew the
“approved” status of a survey vendor.
11. Acknowledge that review of, and agreement with, the Rules of Participation is necessary for
participation.

VII. Applicant Organization Qualification and Acceptance
I certify that
•

•

Authorized Representative

I have reviewed and agree to meet the Rules Name:
of Participation for participating in the QHP Title:
Survey.
Organization:
The statements herein are true, complete Date:
and accurate to the best of my knowledge,
and I accept the obligation to comply with
the Minimum Business Requirements.

For assistance, please contact the Project Team by telephone at [phone number] or e-mail at [email address].