Information Collection

Adult Qualified Health Plan Enrollee Experience Survey

IC 210330 under ICR 202607-0938-016 · OMB 0938-1221.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10488 Survey Vendor Application Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 QHP Survey (Chinese) Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 Cover Letter (Chinese) Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 QHP Survey (English) Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 Cover Letter 1 (English) Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 QHP Survey (Spanish) Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 Cover Letter (Spanish) Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 Chinese Cover Letter - 2 Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 Chinese Prenotification Letter Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 Chinese Reminder Letter Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 English Cover Letter 2 Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 English Cover Letter 2 Adult Qualified Health Plan Enrollee Experience Survey	Form and Instruction
Form CMS-10488 Prenotification Letter - English Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 Prenotification Letter (Spanish) Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 Enrollee Survey Reminder Letter - Spanish Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 QHP Enrollee Survey Internet Script - Chinese Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 QHP - QHP Enrollee Survey Notification Email - Chinese Adult Qualified Health Plan Enrollee Experience Survey	Form
Form CMS-10488 QHP Enrollee Survey Reminder Email - Chinese Adult Qualified Health Plan Enrollee Experience Survey	Form
CMS-10488 Survey Vendor Application 2027QHP-ES-VendorParticipationForm508.pdf	Form and Instruction
CMS-10488 QHP Survey (Chinese) 2027QHP-ES-InstrumentChinese508.pdf	Form and Instruction
CMS-10488 Cover Letter (Chinese) 2027QHP-ES-CoverLetter1Chinese508.pdf	Form
CMS-10488 QHP Survey (English) 2027QHP-ES-InstrumentEnglish508.pdf	Form and Instruction
CMS-10488 Cover Letter 1 (English) 2027QHP-ES-CoverLetter1English508.pdf	Form
CMS-10488 QHP Survey (Spanish) 2027QHP-ES-InstrumentSpanish508.pdf	Form and Instruction
CMS-10488 Cover Letter (Spanish) 2027QHP-ES-Coverletter1Spanish508.pdf	Form and Instruction
CMS-10488 Chinese Cover Letter - 2 2027QHP-ES-CoverLetter2Chinese508.pdf	Form and Instruction
CMS-10488 Chinese Prenotification Letter 2027QHP-ES-PrenotLetterChinese508.pdf	Form
CMS-10488 Chinese Reminder Letter 2027QHP-ES-RemindLetterChinese508.pdf	Form
CMS-10488 English Cover Letter 2 2027QHP-ES-CoverLetter2English508.pdf	Form and Instruction
CMS-10488 English Cover Letter 2 2027QHP-ES-CoverLetter2English508.pdf	Form and Instruction
CMS-10488 Prenotification Letter - English 2027QHP-ES-PrenotLetterEnglish508.pdf	Form
CMS-10488 Prenotification Letter (Spanish) 2027QHP-ES-PrenotLetterSpanish508.pdf	Form
CMS-10488 Enrollee Survey Reminder Letter - Spanish 2027QHP-ES-RemindLetterSpanish508.pdf	Form
CMS-10488 QHP Enrollee Survey Internet Script - Chinese 2027QHP-ES-NetScriptChinese508.pdf	Form
CMS-10488 QHP - QHP Enrollee Survey Notification Email - Chinese 2027QHP-ES-NotifEmailChinese508.pdf	Form
CMS-10488 QHP Enrollee Survey Reminder Email - Chinese 2027QHP-ES-RemindEmailChinese508.pdf	Form
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 156.200(b)(5) 45 CFR 155.200(d)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10488	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Yes	Yes	Fillable Fileable
Form	CMS-10488	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Yes	Yes	Fillable Fileable
Form	CMS-10488	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10488	Yes	Yes	Fillable Fileable
Form	CMS-10488	Yes	No	Paper Only
Form	CMS-10488	Yes	No	Paper Only
Form and Instruction	CMS-10488	Yes	No	Paper Only
Form and Instruction	CMS-10488	Yes	Yes	Paper Only
Form	CMS-10488	Yes	Yes	Paper Only
Form	CMS-10488	Yes	Yes	Paper Only
Form	CMS-10488	Yes	No	Paper Only
Form	CMS-10488	Yes	Yes	Paper Only
Form	CMS-10488	Yes	Yes	Paper Only
Form	CMS-10488	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: 72,000

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	72,000	-25,505	97,505
Annual IC Time Burden (Hours)	36,040	-12,832	48,872
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		09/10/2015

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

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