Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

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

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 2024QHPSrvyVndrPrtcptnFrm-RE.pdf	Form and Instruction
CMS-10488 Survey Vendor Application 2024QHPSrvyVndrPrtcptnFrm-RE.pdf	Form and Instruction
CMS-10488 QHP Survey (Chinese) 2024-QHP-Enroll-Survey-CHI-508.pdf	Form and Instruction
CMS-10488 QHP Survey (Chinese) 2024-QHP-Enroll-Survey-CHI-508.pdf	Form and Instruction
CMS-10488 Cover Letter (Chinese) 2024-QHP-Enrollee-Survey-Cover-Letter-1-Chinese-508.pdf	Form
CMS-10488 Cover Letter (Chinese) 2024-QHP-Enrollee-Survey-Cover-Letter-1-Chinese-508.pdf	Form
CMS-10488 QHP Survey (English) 2024-QHP-Enroll-Survey-ENG-508.pdf	Form and Instruction
CMS-10488 QHP Survey (English) 2024-QHP-Enroll-Survey-ENG-508.pdf	Form and Instruction
CMS-10488 Cover Letter 1 (English) 2024-QHP-Enrollee-Survey-Cover-Letter-1-English-508.pdf	Form
CMS-10488 Cover Letter 1 (English) 2024-QHP-Enrollee-Survey-Cover-Letter-1-English-508.pdf	Form
CMS-10488 QHP Survey (Spanish) 2024-QHP-Enroll-Survey-SPA-508.pdf	Form and Instruction
CMS-10488 QHP Survey (Spanish) 2024-QHP-Enroll-Survey-SPA-508.pdf	Form and Instruction
CMS-10488 Cover Letter (Spanish) 2024-QHP-Enrollee-Survey-Cover-Letter-1-Spanish-508.pdf	Form and Instruction
CMS-10488 Cover Letter (Spanish) 2024-QHP-Enrollee-Survey-Cover-Letter-1-Spanish-508.pdf	Form and Instruction
CMS-10488 Chinese Cover Letter - 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-Chinese-508.pdf	Form and Instruction
CMS-10488 Chinese Cover Letter - 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-Chinese-508.pdf	Form and Instruction
CMS-10488 Chinese Prenotification Letter 2024-QHP-Enrollee-Survey-Prenotification-Letter-Chinese-508.pdf	Form
CMS-10488 Chinese Prenotification Letter 2024-QHP-Enrollee-Survey-Prenotification-Letter-Chinese-508.pdf	Form
CMS-10488 Chinese Reminder Letter 2024-QHP-Enrollee-Survey-Reminder-Letter-Chinese-508.pdf	Form
CMS-10488 Chinese Reminder Letter 2024-QHP-Enrollee-Survey-Reminder-Letter-Chinese-508.pdf	Form
CMS-10488 English Cover Letter 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-English-508.pdf	Form and Instruction
CMS-10488 English Cover Letter 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-English-508.pdf	Form and Instruction
CMS-10488 English Cover Letter 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-English-508.pdf	Form and Instruction
CMS-10488 English Cover Letter 2 2024-QHP-Enrollee-Survey-Cover-Letter-2-English-508.pdf	Form and Instruction
CMS-10488 Prenotification Letter - English 2024-QHP-Enrollee-Survey-Prenotification-Letter-English-508.pdf	Form
CMS-10488 Prenotification Letter - English 2024-QHP-Enrollee-Survey-Prenotification-Letter-English-508.pdf	Form
CMS-10488 Prenotification Letter (Spanish) 2024-QHP-Enrollee-Survey-Prenotification-Letter-Spanish-508.pdf	Form
CMS-10488 Prenotification Letter (Spanish) 2024-QHP-Enrollee-Survey-Prenotification-Letter-Spanish-508.pdf	Form
CMS_10488 Enrollee Survey Reminder Letter - Spanish 2024-QHP-Enrollee-Survey-Reminder-Letter-Spanish-508.pdf	Form
CMS_10488 Enrollee Survey Reminder Letter - Spanish 2024-QHP-Enrollee-Survey-Reminder-Letter-Spanish-508.pdf	Form
CMS-10488 QHP Enrollee Survey Internet Script - Chinese Att-A-2025-QHP-Enrollee-Survey-Internet-Script-Chinese_Revised.docx	Form
CMS-10488 QHP Enrollee Survey Internet Script - Chinese Att-A-2025-QHP-Enrollee-Survey-Internet-Script-Chinese_Revised.docx	Form
CMS-10488 QHP - QHP Enrollee Survey Notification Email - Chinese Att-B-2025-QHP-Enrollee-Survey-Notification-Email-Chinese_Revised.docx	Form
CMS-10488 QHP - QHP Enrollee Survey Notification Email - Chinese Att-B-2025-QHP-Enrollee-Survey-Notification-Email-Chinese_Revised.docx	Form
CMS-10440 QHP Enrollee Survey Reminder Email - Chinese Att-C-2025-QHP-Enrollee-Survey-Reminder-Email-Chinese_Revised.docx	Form
CMS-10440 QHP Enrollee Survey Reminder Email - Chinese Att-C-2025-QHP-Enrollee-Survey-Reminder-Email-Chinese_Revised.docx	Form
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	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Health Insurance Exchange Program

FR Citation: 78 FR 8538

Number of Respondents: 97,505

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	Previously Approved
Annual Number of Responses for this IC	97,505	97,505
Annual IC Time Burden (Hours)	48,872	48,872
Annual IC Cost Burden (Dollars)	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.