Form CMS-10488 Survey Vendor Application

OMB NO. 0938-1221: APPROVAL EXPIRES XX/XX/XXXX

Qualified Health Plan Enrollee Experience Survey

2021 VENDOR PARTICIPATION FORM
A vendor must fulfill all Minimum Business Requirements (MBR) listed below to apply for
consideration to administer the 2020 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 2021 QHP Enrollee Survey on behalf of QHP issuers. Final approval to administer the 2021
QHP Enrollee Survey is contingent on successful completion of 2021 QHP Enrollee Vendor
Training. The 2020 QHP Enrollee Survey Vendor Training is tentatively scheduled for October
XX, 2020. 1
ALL VENDOR PARTICIPATION FORMS AND MATERIALS ARE DUE TO THE QHP
ENROLLEE SURVEY PROJECT TEAM (PROJECT TEAM) BY: July XX, 2020.
Forms should be saved as a PDF with the following naming convention: 2021 QHP Participation
Form_ [Vendor Name]_DDMMYY (e.g., 2021 QHP Participation Form_VendorXYZ_072920.pdf)
Submit completed forms to the Project Team via email at [email protected].
Please note that publication of the 2021 Qualified Health Plan Enrollee Experience Survey
Technical Specifications is anticipated for the end of September 2020. Compliance with the
2021 Qualified Health Plan Enrollee Experience Survey Technical Specifications is required
upon approval as a 2021 QHP Survey Vendor.

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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 09/30/2020.
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 21244-1850.

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I.

General Information

Please complete the section below to provide general organizational information.
1. Organization Name
2. Organization Mailing Address
3. Organization Telephone Number
4. Organization Website Address
5. Number of Years in Business and Date
Company Founded
6. Number of Years Conducting Patient
Experience Surveys by Mode

Mail:
Telephone:
Internet:

7. Number of Years Conducting Mixed
Mode (i.e., Mail, Telephone, Internet)
Patient Experience Surveys
8. Primary Contact Person
(First Name, Last Name; Title;
Degree(s))
9. Primary Contact Mailing Address
10. Primary Contact Telephone Number
11. Primary Contact Email Address

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II.

QHP Enrollee Survey Minimum Business Requirements

Vendors must meet all Minimum Business Requirements. Please check “Yes” or “No” for each
item below to indicate whether your organization meets the following Minimum Business
Requirements.

1. Relevant Survey Experience
Number of Years in Business
☐ Yes

☐ No

Vendor has a minimum of three years’ prior experience administering
standardized patient experience surveys as an organization within the
most recent three-year period (2017-2020).

☐ Yes

☐ No

Vendor has a minimum of three years’ prior experience conducting largescale mixed-mode (mail/telephone/internet) survey protocols within the
most recent three-year period (2017-2020).

☐ Yes

☐ No

Vendor has prior experience administering patient experience surveys for
vulnerable populations.

☐ Yes

☐ No

Vendor has a minimum of two years’ prior experience employing a
statistical sampling process within the most recent three-year period
(2017-2020).

☐ Yes

☐ No

Vendor has prior experience submitting patient experience survey data to
an external third-party organization.

☐ Yes

☐ No

Vendor has been in business for a minimum of four years.

Survey Experience

In reviewing applications, CMS will take into consideration the applicant’s prior experience on
other CMS-sponsored surveys as a vendor.

Prior Experience on CMS-Sponsored Surveys
Vendor has been previously approved to implement other CMSsponsored or CAHPS surveys.

☐ Yes

☐ No

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If your organization has been approved for other CMS-sponsored surveys, list the five most
recent standardized patient experience surveys your organization conducted:
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, MailOnly, TelephoneOnly, Internet-Only)

Language(s)
Administered

Number of
Years
Administering
Survey

1.
2.
3.
4.
5.

Experience with Survey Administration in Multiple Languages
Vendor has prior experience administering mail, telephone, and
internet surveys in English and Spanish.

☐ Yes

☐ No

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

☐ Yes

☐ No

☐ Yes

☐ No

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

Explanation
Please explain any “No” responses to the above Relevant Survey Experience requirements.
Indicate the requirement(s) to which the explanation applies:

Requirement

Explanation

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2. Organizational Survey Capacity
Capacity to Handle Estimated Workload
Vendor has sufficient physical and personnel resources to administer largescale outgoing and incoming mail surveys, perform telephone interviews
using an electronic telephone interviewing system, and administer the
internet survey during the survey fielding period (e.g., February through
May).

☐ Yes

☐ No

Vendor conducts all survey-related activities within the Continental United
States, Hawaii, Alaska, and U.S. Territories. This requirement applies to all
staff and subcontractors.

☐ Yes

☐ No

Vendor has the capacity to adhere to requirements specified in the 2021
Qualified Health Plan Enrollee Experience Survey Technical Specifications.

☐ Yes

☐ No

Vendor has a designated Project Manager, who is an employee (i.e., not a
subcontractor), who oversees all survey operations and has at least three
years of experience in overseeing all functional aspects of survey
operations including mail, telephone, internet, data file preparation, and
data security. Must have a strong background in survey research and
methodology and previous experience using mixed-mode administration,
as evidenced by the Curriculum Vitae (CV).

☐ Yes

☐ No

Vendor has a designated Mail Survey Supervisor with a minimum of one
year’s previous experience managing large-scale mail survey projects.

☐ Yes

☐ No

Vendor has a designated Telephone Center Survey Supervisor with a
minimum of one year’s previous experience managing large-scale
telephone interviewing projects.

☐ Yes

☐ No

Vendor has a designated Internet Survey Supervisor with a minimum of
one year’s previous experience managing large-scale internet survey
projects.

☐ Yes

☐ No

Vendor has a designated Sampling Manager, directly employed by the
vendor (i.e., not a subcontractor), with a minimum of one year’s previous
experience with sample frame development and sample selection.

☐ Yes

☐ No

Vendor has designated Information System staff responsible for data
submission (programmer) who are directly employed by the vendor (i.e.,
not a subcontractor) and have a minimum of one year’s previous
experience preparing and submitting data files in a specified format to
external third-party organization(s).

☐ Yes

☐ No

Personnel

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Vendor has appropriate organizational back-up staff for coverage of key
staff, in terms of sufficiency and experience.

☐ Yes

☐ No

Vendor’s commercial physical plant and system resources meet CMS
specifications and accommodate the volume of surveys being
administered. Note: All system resources are subject to oversight activities,
including onsite visits to physical locations.

☐ Yes

☐ No

Vendor and its designated subcontractors (if applicable) conduct business
operations and all vendor-related work, including mail and internet survey
administration and telephone interviewing, at the vendor’s or approved
subcontractor’s official business location. Home-based places of work (e.g.,
residences) and virtual organizations will not be considered.

☐ Yes

☐ No

Vendor has the capacity to reproduce and mail questionnaires, cover
letters and reminder letters at the vendor’s or subcontractor’s official
business location, as outlined in 2021 Qualified Health Plan Enrollee
Experience Survey Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to process (e.g., scan or key enter) incoming
paper surveys at the vendor’s or designated subcontractor’s official
business location, as outlined in 2021 Qualified Health Plan Enrollee
Experience Survey Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to program electronic telephone interview systems
in accordance with specifications provided and to conduct telephone
interviews using an electronic telephone interviewing system at the
vendor’s or subcontractor’s official business location, as outlined in the
2021 Qualified Health Plan Enrollee Experience Survey Quality Technical
Specifications.

☐ Yes

☐ No

Vendor has the capacity to produce and program the internet survey
instrument and all required emails in-house.

☐ Yes

☐ No

Vendor has the capacity to produce a mobile-ready version of the internet
survey in-house.

☐ Yes

☐ No

Vendor can handle concurrent survey projects while maintaining highquality survey data and response rates.

☐ Yes

☐ No

Vendor has an electronic survey management system that tracks fielded
surveys through each stage of the protocol via random, unique de-identified
enrollee identification numbers and interim disposition codes. The
electronic survey management system prevents duplicative records.

☐ Yes

☐ No

Vendor has the capacity to provide regular progress reports to QHP
issuers, within guidelines specified by CMS.

☐ Yes

☐ No

System Resources

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Vendor maintains 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 personally
identifiable information (PII).

☐ Yes

☐ No

Vendor has the resources to prepare, accommodate, and plan for onsite
visits from CMS or the CMS-sponsored Project Team for quality oversight
purposes.

☐ Yes

☐ No

Vendor can print, assemble, and mail survey materials in accordance with
the 2021 Qualified Health Plan Enrollee Experience Survey Technical
Specifications.

☐ Yes

☐ No

Vendor can program the electronic telephone interviewing system in
accordance with the 2021 Qualified Health Plan Enrollee Experience
Survey and Technical Specifications.

☐ Yes

☐ No

Vendor can produce and program the internet survey instrument in
accordance with the 2021 Qualified Health Plan Enrollee Experience
Survey Technical Specifications.

☐ Yes

☐ No

Vendor can comply with all quality oversight requirements described in the
2021 Qualified Health Plan Enrollee Experience Survey Quality Assurance
Guidelines and Technical Specifications. This includes the submission of
sample mail materials, sample telephone scripts and interviewer screen
shots, and an internet survey test link and test emails to the Project Team
for review and approval prior to survey administration.

☐ Yes

☐ No

Vendor demonstrates ability to collect and accurately process survey data
through all phases of survey administration.

☐ Yes

☐ No

Vendor has demonstrated experience identifying and contacting
nonrespondents for mail and telephone follow-up.

☐ Yes

☐ No

Vendor has the capacity to adhere to the survey administration timeline.

☐ Yes

☐ No

Vendor has experience using commercial software/resources to verify that
addresses and telephone numbers are updated and correct for all sampled
enrollees.

☐ Yes

☐ No

Vendor has the capability to administer the survey in Spanish (and
Chinese, if applicable).

☐ Yes

☐ No

Vendor can assign appropriate disposition codes to each sampled enrollee
to indicate final survey status.

☐ Yes

☐ No

Vendor’s mail and internet survey administration activities and telephone
interviews are not conducted from any residences (i.e., no remote, homebased or virtual work).

☐ Yes

☐ No

Mode Administration

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Sampling Experience
Vendor has consistent experience in the two most recent years (20182020), selecting random samples based on specific eligibility criteria.

☐ Yes

☐ No

Vendor must document its statistical approach to drawing a sample and
demonstrate its ability to work with QHP issuer(s) to electronically obtain
sample frame(s) for sampling within a specified time frame.

☐ Yes

☐ No

Vendor must conduct quality checks on sample frame file(s) to verify
accuracy and completeness of sample frame information.

☐ Yes

☐ No

Vendors must conduct the sampling process in-house and must not
subcontract this activity.

☐ Yes

☐ No

Vendor has the capability to scan or key enter data per protocols detailed in
the 2021 Qualified Health Plan Enrollee Experience Survey Technical
Specifications.

☐ Yes

☐ No

Vendor has the capacity to follow all data preparation and submission rules
as specified in the 2021 Qualified Health Plan Enrollee Experience Survey
Technical Specifications, including verifying data are de-identified and
contain no duplicate cases.

☐ Yes

☐ No

Vendor can submit data electronically in the format specified in the 2021
Qualified Health Plan Enrollee Experience Survey Technical Specifications.

☐ Yes

☐ No

Vendor will execute Business Associate Agreement(s) with QHP issuer(s)
and receive annual authorization from QHP issuer(s) to collect data on their
behalf and submit these data to CMS.

☐ Yes

☐ No

Vendor will work with the Project Team to resolve data and data file
submission problems.

☐ Yes

☐ No

Vendor maintains established electronic security procedures related to
access levels, passwords, and firewalls as required by HIPAA.

☐ Yes

☐ No

Vendor performs daily data back-up and offsite redundancy procedures
that adequately safeguard system data.

☐ Yes

☐ No

Vendor develops a disaster recovery plan for conducting ongoing business
operations in the event of a disaster.

☐ Yes

☐ No

Vendor has the capacity to use required encryption protocols, if applicable,
to transmit data files. CMS-defined PII must be transmitted securely (e.g.,
encrypted file via email, data portal, or SFTP).

☐ Yes

☐ No

Data Submission

Data Security and Retention

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

☐ Yes

☐ No

Vendor will prepare and submit data via secure methods (HIPAA
compliant).

☐ Yes

☐ No

Vendor has the capacity to retain all data files for a minimum of three
years, or as otherwise specified by CMS.

☐ Yes

☐ No

Vendor has the capacity to store returned paper questionnaires in a secure
and environmentally safe location, either onsite or using an offsite
contractor.

☐ Yes

☐ No

Vendor has the capacity to store data files (paper and/or electronic)
securely and confidentially in accordance with specified requirements.

☐ Yes

☐ No

Vendor has the capacity and resources to ensure confidentiality of data for
sampled enrollees’ PII and survey responses during each phase of the
survey process.

☐ Yes

☐ No

Vendor will obtain signed confidentiality agreements from staff and
subcontractors.

☐ Yes

☐ No

Vendor has the capacity and resources to comply with all applicable HIPAA
Security and Privacy Rules, Protected Health Information (PHI), and
Personally Identifiable Information (PII) protocols in conducting all survey
administration and data collection activities.

☐ Yes

☐ No

Vendor has the capacity to establish toll-free customer support telephone
lines with a live operator during regular vendor business hours to
accommodate both English and Spanish inquiries throughout the duration
of survey fielding.

☐ Yes

☐ No

If administering the survey in Chinese (Mandarin), vendor has the capacity
and resources to accommodate telephone inquiries from Chinese-speaking
survey participants.

☐ Yes

☐ No

Confidentiality

Technical Assistance/Customer Support

Explanation
Please explain any “No” responses to the above Organizational Survey Capacity requirements.
Indicate the requirement(s) to which the explanation applies:

Requirement

Explanation

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3. Quality Control Procedures
Demonstrated Quality Control Procedures
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 surveys (electronic telephone interviewing system); internet
administration of surveys; scanning and coding of survey data; monitoring
subcontractors (if applicable); preparing final data files for submission; and
all other functions and processes that affect the administration of the QHP
Enrollee Survey as specified in the 2021 Qualified Health Plan Enrollee
Experience Survey Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to develop and submit annually a Quality
Assurance Plan (QAP) for administration in accordance with the 2021
Qualified Health Plan Enrollee Experience Survey Technical Specifications
that provides written evidence of the processes used to collect and
accurately process survey data through all phases of fielding.

☐ Yes

☐ No

Physical business premises on which major survey operations are
conducted are amenable to onsite visits by CMS and the CMS-sponsored
Project Team, as specified in the 2021 Qualified Health Plan Enrollee
Experience Survey Technical Specifications.

☐ Yes

☐ No

Explanation
Please explain any “No” responses to the above Quality Control Procedures requirements.
Indicate the requirement(s) to which the explanation applies:

Requirement

Explanation

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III.
Name

List of Key Project Staff
Role

Years with
Organization

Email Address

Telephone
Number

1.
2.
3.
4.
5.

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IV.

Subcontractors

Subcontractors
Check here if your organization does not plan to use subcontractors for the
2020 QHP Enrollee Survey administration.

Response
☐

Please complete the following section for each subcontractor your organization plans to use for
2021 QHP Enrollee Survey administration. The following requirements must be met:

•
•

•
•

Each subcontractor must meet the criteria outlined for the survey administration activity
that it will conduct.
The subcontracting of printing, outgoing mail processing, data entry/scanning, and
telephone interviewing and/or customer support by a vendor is limited to a reasonable
number of subcontractors based on the vendor’s estimated number of surveyed
enrollees and subject to CMS review.
The subcontracting of sample file generation, email or internet survey administration,
and/or data file preparation and submission is not allowed.
All subcontractors are subject to CMS approval.

Subcontractor Name(s), Role(s) and Experience
Subcontractor 1
1. Subcontractor 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(s)
7. Experience Related to Survey
Administration Role(s), Including Names of
Relevant Projects

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Subcontractor 2
1. Subcontractor 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(s)
7. Experience Related to Survey
Administration Role(s), Including Names
of Relevant Projects

Subcontractor 3
1. Subcontractor 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(s)
7. Experience Related to Survey
Administration Role(s), Including Names
of Relevant Projects

Subcontractor 4
1. Subcontractor 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(s)
7. Experience Related to Survey
Administration Role(s), Including Names
of Relevant Projects

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V.

Curriculum Vitae (CV)

Please submit a CV for all identified key vendor staff and subcontractor staff, if applicable, via
email to the Project Team at [email protected]. Please ensure subject line in email
reads, “[Vendor Name] Key Staff CV Submission”.

VI.

Participation Rules

Any vendor participating in 2021 QHP Enrollee Survey administration must adhere to the
following Participation Rules. To be eligible, the organization must:
1. Meet the 2021 QHP Enrollee Survey Minimum Business Requirements (MBR).
2. 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).
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.
Subcontractor attendance is optional.
4. Review and comply with the 2021 Qualified Health Plan Enrollee Experience Survey
Technical Specifications and any policy updates.
5. Develop and submit a vendor Quality Assurance Plan (QAP) as specified by the deadline
determined by CMS. In addition, submit materials relevant to the survey administration (as
determined by CMS), including mailing materials (e.g., cover letters, questionnaires,
reminder letters and envelopes), telephone scripts and the internet survey instrument.
6. Participate and cooperate (including subcontractors) in all oversight activities conducted by
the Project Team, including but not limited to: survey material review, onsite/remote site
visits, seeded mailings, telephone interview monitoring, data review, and other oversight
activities as determined by CMS.
7. Acknowledge that the use of virtual telephone interviewers is prohibited.
8. Comply with all rules and regulations pertaining to personally identifiable information (PII)
and Protected Health Information (PHI) per the Health Insurance Portability and
Accountability Act (HIPAA).
9. Submit an interim survey data file to CMS, as determined by CMS.

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10. Submit data on time, as specified by the deadline determined by CMS.
11. Attest to the accuracy of the organization’s data collection (as determined by CMS) and
follow the guidelines set forth in the 2021 Qualified Health Plan Enrollee Experience Survey
Technical Specifications.
12. Notify the Project Team of any discrepancies or variations from standard QHP Enrollee
Survey protocols that occur as the discrepancy is identified. The vendor must complete and
submit a Discrepancy Report (in the format and manner specified by CMS) within one
business day of becoming aware of the discrepancy. Vendors must notify QHP issuer clients
whenever a Discrepancy Report is submitted to the Project Team regarding their reporting
unit(s), as applicable.
13. Attest that the vendor is organizationally independent from the QHP issuer client; the vendor
must not administer the QHP Enrollee Survey or produce survey results to meet CMS
requirements for any QHP client issuer that controls, is controlled by, or is under common
control with the vendor.
14. Acknowledge that contracting with and successfully administering the QHP Enrollee Survey
on behalf of at least one QHP issuer within 24 months of receiving initial approval status is a
requirement for continued approval status. A vendor must continue to field the survey for at
least one QHP issuer during every 24-month increment following the initial 24-month period.
15. Acknowledge that CMS may, at its sole discretion, terminate or discontinue the “approved”
status of a vendor. CMS may exercise these actions at any point during survey
administration.
16. Acknowledge that review of and agreement with the Rules of Participation is necessary for
participation.

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VII. Applicant Organization Qualification and Acceptance
I certify that:

Authorized Representative

•

I have reviewed and agree to meet the Name:
Rules of Participation for participating in the
Title:
2021 QHP Enrollee Survey.

•

The statements herein are true, complete Organization:
and accurate to the best of my knowledge,
and I accept the obligation to comply with Date:
the 2021 QHP Enrollee Survey Minimum
Business Requirements.

For assistance, please contact the Project Team by email at [email protected].

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