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Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 202407-0938-021 · OMB 0938-1221.

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Adult Qualified Health Plan Enrollee Experience Survey
 
No Modified
 
Voluntary
 
45 CFR 155.200(d) 45 CFR 156.200(b)(5)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10488 Survey Vendor Application 2024QHPSrvyVndrPrtcptnFrm-RE.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Survey (Chinese) 2024-QHP-Enroll-Survey-CHI-508.pdf Yes Yes Fillable Fileable
Form CMS-10488 Cover Letter (Chinese) 2024-QHP-Enrollee-Survey-Cover-Letter-1-Chinese-508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Survey (English) 2024-QHP-Enroll-Survey-ENG-508.pdf Yes Yes Fillable Fileable
Form CMS-10488 Cover Letter 1 (English) 2024-QHP-Enrollee-Survey-Cover-Letter-1-English-508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 QHP Survey (Spanish) 2024-QHP-Enroll-Survey-SPA-508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 Cover Letter (Spanish) 2024-QHP-Enrollee-Survey-Cover-Letter-1-Spanish-508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10488 Chinese Cover Letter - 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-Chinese-508.pdf Yes Yes Fillable Fileable
Form CMS-10488 Chinese Prenotification Letter 2024-QHP-Enrollee-Survey-Prenotification-Letter-Chinese-508.pdf Yes No Paper Only
Form CMS-10488 Chinese Reminder Letter 2024-QHP-Enrollee-Survey-Reminder-Letter-Chinese-508.pdf Yes No Paper Only
Form and Instruction CMS-10488 English Cover Letter 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-English-508.pdf Yes No Paper Only
Form and Instruction CMS-10488 English Cover Letter 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-English-508.pdf Yes Yes Paper Only
Form CMS-10488 Prenotification Letter - English 2024-QHP-Enrollee-Survey-Prenotification-Letter-English-508.pdf Yes Yes Paper Only
Form CMS-10488 Prenotification Letter (Spanish) 2024-QHP-Enrollee-Survey-Prenotification-Letter-Spanish-508.pdf Yes Yes Paper Only
Form CMS_10488 Enrollee Survey Reminder Letter - Spanish 2024-QHP-Enrollee-Survey-Reminder-Letter-Spanish-508.pdf Yes No Paper Only
Form CMS-10488 QHP Enrollee Survey Internet Script - Chinese Att-A-2025-QHP-Enrollee-Survey-Internet-Script-Chinese_Revised.docx Yes Yes Paper Only
Form CMS-10488 QHP - QHP Enrollee Survey Notification Email - Chinese Att-B-2025-QHP-Enrollee-Survey-Notification-Email-Chinese_Revised.docx Yes Yes Paper Only
Form CMS-10440 QHP Enrollee Survey Reminder Email - Chinese Att-C-2025-QHP-Enrollee-Survey-Reminder-Email-Chinese_Revised.docx Yes Yes Paper Only

Health Health Care Services

Health Insurance Exchange Program  78 FR 8538

97,505 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 97,505 0 0 0 0 97,505
Annual IC Time Burden (Hours) 48,872 0 0 0 0 48,872
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.