Form CMS-10488 Survey Vendor Application

Qualified Health Plan Enrollee Experience Survey

2016 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 Enrollee Experience Survey (QHP Enrollee Survey) on behalf of QHP issuers.
This Participation Form is to be completed by organizations requesting approval to administer the 2016
QHP Enrollee Survey on behalf of QHP issuers. Final approval for the 2015 QHP Enrollee Survey is
contingent on successful completion of 2015 QHP Enrollee Survey Vendor Training (tentatively
scheduled for late October, 2015).
ALL SURVEY VENDOR PARTICIPATION FORMS AND MATERIALS ARE DUE BY: July 10,
2015
PARTICIPATION STATUS

DATE SUBMITTED

☐ New Participation Form

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
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this
information collection is 0938-1221. The time required to complete this information collection is estimated to average 90
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. The expiration date for this form is MM/DD/YYYY.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 212441850.

II.

QHP Enrollee 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/telephone/Internet) survey administration for a minimum
of two years within the most recent three year period.

☐ 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 within the two
most recent years.

☐ Yes

☐ No

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

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

In reviewing applications, CMS will take into consideration the applicants’ prior experience on
other CMS- sponsored or CAHPS surveys as a survey vendor.
Survey vendor has been approved as a survey vendor to implement other
☐ Yes ☐ No
CMS-sponsored or CAHPS surveys?

If Yes, list the five most recent standardized 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, Internet
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
English and Spanish.

☐ Yes

☐ No

Is your organization seeking CMS approval to administer the QHP Enrollee
Survey in Chinese?

☐ Yes

☐ No

[If applying to administer the QHP Enrollee Survey in Chinese]
Survey vendor has prior experience administering mail surveys in Traditional
Chinese and telephone surveys in Mandarin.

☐ Yes

☐ No

2. Organization Survey Capacity
Capacity to Handle Estimated Workload
Survey vendor has sufficient physical and personnel resources to administer
large-scale outgoing and incoming mail surveys, to perform telephone
interviews using an electronic telephone interviewing system, and to
administer the Internet Survey during the survey fielding time period
(estimated January through April of calendar year). All survey-related
activities must be conducted within the Continental United States, Hawaii and
Alaska and U.S. Territories. Survey vendor must adhere to requirements
specified in Qualified Health Plan Enrollee Experience Survey Quality
Assurance Guidelines and Technical Specifications.

☐ Yes

☐ No

Personnel
Survey vendor has a designated Project Manager, who is directly employed
by the survey vendor (i.e., not a subcontractor), overseeing all survey
operations with at least two years of experience in overseeing all functional
aspects of survey operations including mail, telephone, Internet, 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.

☐ Yes

☐ No

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

☐ Yes

☐ No

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

☐ Yes

☐ No

Survey vendor has a designated Internet Survey Supervisor with previous
experience managing large scale Internet projects.

☐ Yes

☐ No

Survey vendor has a designated Sampling Manager, who is directly employed
by the survey vendor (i.e., not a subcontractor), with sample frame
development and sample selection experience.

☐ Yes

☐ No

Survey vendor has designated Information System staff responsible for data
submission (programmer) who are directly employed by the survey vendor
(i.e., not a subcontractor) and has previous experience preparing and
submitting data files in specified format to external third-party organizations
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 and all survey-vendor related work, including mail and
Internet survey administration and telephone interviewing, from a commercial
☐ Yes
physical plant, which is considered as the official business location. Homebased places of work (e.g., residences) and virtual organizations will not be
considered.

☐ 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.” Incoming paper surveys will
be processed (e.g. scanned or data entered) at a survey vendor’s, or their
designated subcontractor’s, official business location.

☐ No

System Resources

☐ Yes

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

☐ Yes

☐ No

Survey vendor has capacity for producing and programming the Internet
survey instrument in-house.

☐ Yes

☐ No

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

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 Enrollee Experience 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 quality oversight requirements described
in the Qualified Health Plan Enrollee Experience Survey Quality Assurance
Guidelines and Technical Specifications, including submitting telephone
script or screen shots for review prior to initiation of telephone interviewing
conducted by survey vendor or telephone subcontractor interviewers.

☐ Yes

☐ No

Survey vendor will comply with all quality oversight requirements described
in the Qualified Health Plan Enrollee Experience Survey Quality Assurance
Guidelines and Technical Specifications, including submitting a link to the
Internet survey along with five user IDs and passwords for review prior to
circulation.

☐ Yes

☐ No

Survey vendor has capacity to handle concurrent survey projects while
maintaining high quality survey data and high response rates.

☐ 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 verify
that addresses and telephone numbers are updated and correct for all sampled
enrollees.

☐ Yes

☐ No

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

☐ Yes

☐ No

Survey vendor will prepare, accommodate, and plan for on-site visits from
CMS or CMS-sponsored Project Team for quality oversight purposes.

☐ Yes

☐ No

☐ 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 preparation and submission rules as
specified in the Qualified Health Plan Enrollee Experience 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.

☐ Yes

☐ No

Survey vendor will execute business associate agreements with QHP issuers
and receive annual authorization from QHP issuers 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

Survey vendor will store returned paper questionnaires 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 as required by HIPAA.

☐ Yes

☐ No

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

☐ 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 QHP issuers to electronically obtain sample frame for
sampling. Must conduct quality checks on sample frame file received from
QHP issuer to verify accuracy and completeness of sample frame
information.

Data Submission

Data Security and Retention

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

☐ Yes

☐ No

Survey vendor will retain all data files for a minimum of three years, or as
otherwise specified by CMS.

☐ 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 will
verify confidentiality of sampled enrollees identifying information and survey
responses during each phase of the survey process. Survey vendor will obtain
signed confidentiality agreements from staff and subcontractors.

Technical Assistance/Customer Support
Survey vendor has the capacity to establish either an 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; Internet administration; 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
Enrollee Experience 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.
4.
5.

Role

Number of
Years with
Organization

E-mail

Telephone

IV.

Subcontractors

Check here if you do not plan to use subcontractors for the QHP Enrollee
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 Website.

VI.

Participation Rules

Any survey vendor participating in the QHP Enrollee Survey 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 Enrollee Survey Vendor Training and all subsequent
QHP Enrollee Survey Vendor update trainings. At a minimum, the organization’s project manager,
mail survey supervisor, telephone survey supervisor, Internet 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 Enrollee Experience 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 Enrollee Experience
Survey Quality Assurance Guidelines and Technical Specifications.
6. Develop and submit a survey vendor Quality Assurance Plan (QAP) by the due date. In addition,
submit materials relevant to the survey administration (as determined by CMS), including mailing
materials (e.g., cover letters and questionnaires), telephone scripts and the Internet survey
instrument.
7. Participate and cooperate (including subcontractors) in all oversight activities conducted by the
Project Team.
8. Survey vendor may not produce survey results for a QHP client issuer that controls, is controlled by,
or is under common control with the survey vendor.
9. Within 24 months of receiving its initial approved survey vendor status, survey vendor must
successfully field the QHP Enrollee Survey for at least one client. A survey vendor must continue to
field at least one QHP Enrollee Survey during every 24 month increment following the initial 24
month period.
10. Submit data on time according to CMS-specified deadlines. No late submissions will be allowed.
11. Acknowledge that CMS may, at its sole discretion, terminate, discontinue or not renew the
“approved” status of a survey vendor.
12. 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 of Name:
Participation for participating in the QHP Title:
Enrollee Survey.
Organization:
The statements herein are true, complete and Date:
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 844-849-5243 or e-mail
at [email protected].