Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 202206-0938-025 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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 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 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 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 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 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 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 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 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 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 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 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
CMS-10488 - Appendix A _Clean.docx CMS-10488 - Goals of the Psychometric and Beta Test Goals	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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

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: 105,010

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	105,010	22,510	82,500
Annual IC Time Burden (Hours)	54,050	4,500	49,550
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.