Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 201508-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Survey Vendor Application CMS-10488 - 2016 Survey Vendor Application_071415_Clean.pdf	Form and Instruction
CMS-10488 QHP Survey (Chinese) CMS-10488 - Chinese_QHPSurvey2016_508_071315_Final.pdf	Form and Instruction
CMS-10488 Cover Letter (Chinese) CMS-10488 - QHP_CoverLetter_Chinese_508_071315_Final.pdf	Form and Instruction
CMS-10488 QHP Survey (English) CMS-10488 - English_QHPSurvey2016_071315_Clean.pdf	Form and Instruction
CMS-10488 Cover Letter (English) CMS-10488 - QHP_CoverLetter_English_071315_Final.pdf	Form and Instruction
CMS-10488 QHP Survey (Spanish) CMS-10488 - Spanish_QHPSurvey2016_508_071315_Final.pdf	Form and Instruction
CMS-10488 Cover Letter (Spanish) CMS-10488 - QHP_CoverLetter_Spanish_508_071315_Final.pdf	Form and Instruction
CMS-10488 - Appendix A _Clean.docx CMS-10488 - Goals of the Psychometric and Beta Test Goals	IC Document

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 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	Survey Vendor Application	CMS-10488 - 2016 Survey Vendor Application_071415_Clean.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Survey (Chinese)	CMS-10488 - Chinese_QHPSurvey2016_508_071315_Final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Cover Letter (Chinese)	CMS-10488 - QHP_CoverLetter_Chinese_508_071315_Final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Survey (English)	CMS-10488 - English_QHPSurvey2016_071315_Clean.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Cover Letter (English)	CMS-10488 - QHP_CoverLetter_English_071315_Final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Survey (Spanish)	CMS-10488 - Spanish_QHPSurvey2016_508_071315_Final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Cover Letter (Spanish)	CMS-10488 - QHP_CoverLetter_Spanish_508_071315_Final.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120,015

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	120,015	-59,995	180,010
Annual IC Time Burden (Hours)	39,623	-17,987	57,610
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10488 - Goals of the Psychometric and Beta Test Goals	CMS-10488 - Appendix A _Clean.docx	09/10/2015

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