Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 202009-0938-018 · OMB 0938-1221.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1221 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10488 Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
CMS-10488 Survey Vendor Application 2021_QHP_Enrollee_Survey_Vendor_Participation_Form.pdf	Form and Instruction
CMS-10488 QHP Survey (Chinese) 2021 QHP Enrollee Survey Instrument Chinese.docx	Form and Instruction
CMS-10488 Cover Letter (Chinese) 2020-QHP-Chinese Cover Sheet.docx	Form
CMS-10488 QHP Survey (English) 2021 QHP Enrollee Survey Instrument English.docx	Form and Instruction
CMS-10488 Cover Letter 1 (English) 2018-QHP-Eng-Cover1-031317-clean.docx	Form
CMS-10488 QHP Survey (Spanish) 2021 QHP Enrollee Survey Instrument Spanish.docx	Form and Instruction
CMS-10488 Cover Letter (Spanish) CMS-10488 - QHP_CoverLetter_Spanish.pdf	Form and Instruction
CMS-10488 Chinese Cover Letter - 2 2018-QHP-Ch-Cover2-031317-clean.docx	Form and Instruction
CMS-10488 Chinese Prenotification Letter 2021-QHP-Enrollee-Survey-Prenotification-Letter-Chinese.pdf	Form
CMS-10488 Chinese Reminder Letter 2021-QHP-Enrollee-Survey-Reminder-Letter-Chinese.pdf	Form
CMS-10488 English Cover Letter 2 QHP-Eng-Cover2.docx	Form and Instruction
CMS-10488 English Cover Letter 2 2018-QHP-Eng-Prenot-031317-clean.docx	Form and Instruction
CMS-10488 - Appendix A _Clean.docx CMS-10488 - Goals of the Psychometric and Beta Test Goals	IC Document

IC Title:

Adult Qualified Health Plan Enrollee Experience Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 155.200(d) 45 CFR 156.200(b)(5)

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-10488	Survey Vendor Application	2021_QHP_Enrollee_Survey_Vendor_Participation_Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Survey (Chinese)	2021 QHP Enrollee Survey Instrument Chinese.docx	Yes	Yes	Fillable Fileable
Form	CMS-10488	Cover Letter (Chinese)	2020-QHP-Chinese Cover Sheet.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Survey (English)	2021 QHP Enrollee Survey Instrument English.docx	Yes	Yes	Fillable Fileable
Form	CMS-10488	Cover Letter 1 (English)	2018-QHP-Eng-Cover1-031317-clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	QHP Survey (Spanish)	2021 QHP Enrollee Survey Instrument Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Cover Letter (Spanish)	CMS-10488 - QHP_CoverLetter_Spanish.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Chinese Cover Letter - 2	2018-QHP-Ch-Cover2-031317-clean.docx	Yes	Yes	Fillable Fileable
Form	CMS-10488	Chinese Prenotification Letter	2021-QHP-Enrollee-Survey-Prenotification-Letter-Chinese.pdf	Yes	No	Paper Only
Form	CMS-10488	Chinese Reminder Letter	2021-QHP-Enrollee-Survey-Reminder-Letter-Chinese.pdf	Yes	No	Paper Only
Form and Instruction	CMS-10488	English Cover Letter 2	QHP-Eng-Cover2.docx	Yes	No	Paper Only
Form and Instruction	CMS-10488	English Cover Letter 2	2018-QHP-Eng-Prenot-031317-clean.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 82,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	82,500	-7,515	90,015
Annual IC Time Burden (Hours)	49,550	-7,680	57,230
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10488 - Goals of the Psychometric and Beta Test Goals	CMS-10488 - Appendix A _Clean.docx	09/10/2015

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