CMS-10555 SHOP Notices - Employee Survey

Attachment 3. SHOP Survey – Employee

OMB #: 0938-

Expiration Date:

*General note: Add SHOP Marketplace logo as header to all pages.

Learning about the SHOP Marketplace:

Enrollment:

Help with the SHOP Marketplace:

Plan and benefits:

Customer demographics (optional):

What state is your office or worksite located. (*Check all that apply.) (Drop down)?

What industry do you work in? (Text response)

What is the name of the business(es) offering you SHOP coverage? (Text response)

Do you have access to other forms of health coverage (this includes health insurance, whether or not you choose to enroll in coverage, through your spouse, another government program, or another employer that is available to you and for which you qualify)

Yes/no

[Ask if Yes] Tell us what other form of health coverage you have? (Drop down)

1. Individual private health insurance

2. Insurance from another job

3. Insurance through another person’s job

4. Medicare

5. Medicaid

6. TRICARE

7. VA health care programs

8. Indian Health Service

9. I don’t have access to any other health coverage

Resources/recommendations:

1