Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 201501-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

IC Title:

Adult Qualified Health Plan Enrollee Experience Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

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

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	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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	180,010	180,010
Annual IC Time Burden (Hours)	57,610	57,610
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.