Information Collection

CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey

IC 240090 under ICR 201904-0938-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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-10726 CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey	Form and Instruction
CMS-10726 Consumer and Issuer Recruitment Language Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx	Form and Instruction
CMS-10726 Consent Forms Attachment B-Consent Forms.docx	Form and Instruction
CMS-10726 Descripton of Focus Groups and Cognitive Testing Protoco Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx	Form and Instruction
CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx CMS-10726 Generic Clearance	IC Document

IC Title:

CMS-10726 Survey Refinement for the Qualified Health Plan Enrollee Experience Survey

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10726	Consumer and Issuer Recruitment Language	Attachment A-Consumer and Issuer Recruitment Language (FG and CT).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10726	Consent Forms	Attachment B-Consent Forms.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10726	Descripton of Focus Groups and Cognitive Testing Protocols	Attachment C-Detailed Description of Focus Groups and Cognitive Testing Protocols-01242020.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10726 Generic Clearance	CMS-10726 QHP Survey Focus Group Cog Testing Fast Track_Generic Clearance 01242020-revised-CLEAN.docx	02/24/2020

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