Information Collection

Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534)

IC 219433 under ICR 201512-0938-013 · OMB 0938-1185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10534 Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534)	Form and Instruction
CMS-10534 Cognitive Interview Guide, Screener and Consent Forms Report Task Attachments081814.pdf	Form and Instruction
Generic Clearance Submission_Report_v4_clean.docx Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys: Health Insurance Marketplace Consumer Experience Surveys Project (CMS-10534)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10534	Cognitive Interview Guide, Screener and Consent Forms	Report Task Attachments081814.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 15

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	106	106
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Reporting for the Health Insurance Marketplace and Qualified Health Plan Enrollee Experience Surveys	Generic Clearance Submission_Report_v4_clean.docx	12/29/2015

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