Form CMS-10488 Survey Vendor Application

OMB NO. 0938-1221: APPROVAL EXPIRES 11/30/2023

Qualified Health Plan Enrollee Experience Survey
2024 VENDOR PARTICIPATION FORM
Vendors requesting approval to administer the 2024 Qualified Health Plan Enrollee Experience
Survey (QHP Enrollee Survey) on behalf of QHP issuers must complete this Participation Form.
Prospective vendors must fulfill all requirements outlined in the 2024 QHP Enrollee Survey
Minimum Business Requirements (MBR) and listed below before applying for consideration to
administer the 2024 QHP Enrollee Survey on behalf of QHP issuers.
Prospective vendors must submit completed Participation Forms to qhp_survey@air.org in PDF
format with the following naming convention: 2024 QHP Participation Form_ [Vendor
Name]_DDMMYY (e.g., 2024 QHP Participation Form_VendorXYZ_071423.pdf). Vendors must
also submit a curriculum vitae (CV) for all identified vendor and subcontractor key project staff.
ALL VENDOR PARTICIPATION FORMS AND MATERIALS ARE DUE TO THE QHP
ENROLLEE SURVEY PROJECT TEAM (PROJECT TEAM) BY: JULY 14, 2023, AT 11:59
P.M. (ET).
Survey vendors that are granted conditional approval must complete 2024 QHP Enrollee Survey
Vendor Training to earn final approval to administer the 2024 QHP Enrollee Survey. The
tentative date for 2024 QHP Enrollee Survey Vendor Training is September 28, 2023. 1
Please note that the Qualified Health Plan Enrollee Experience Survey: Technical Specifications
for 2024 (2024 Technical Specifications) will be published by October 2023. Prospective
vendors must comply with the 2024 Technical Specifications for approval as a 2024 QHP
Enrollee Survey Vendor.

1 According

to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for
this information collection is 0938-1221. The time required to complete this information collection is estimated to
average 100 minutes per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. The expiration date for this form is 11/30/2023.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

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I.

General Information

Please complete the section below to provide general organizational information.
1. Organization Name
2. Organization Mailing Address
3. Organization Telephone Number
4. Organization Website Address
5. Number of Years in Business and Date
Company Founded
6. Number of Years Conducting Patient
Experience Surveys by Mode

Mail:
Telephone:
Internet:

7. Number of Years Conducting Mixed-Mode
(i.e., Mail, Telephone, and Internet) Patient
Experience Surveys
8. Primary Contact Person
(First Name, Last Name; Title; Credentials)
9. Primary Contact Mailing Address
10. Primary Contact Telephone Number
11. Primary Contact Email Address

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II.

QHP Enrollee Survey Minimum Business Requirements

Vendors must meet all Minimum Business Requirements.
Please check “Yes” or “No” for each item below to indicate your organization’s compliance with
the following Minimum Business Requirements.

1. Relevant Survey Experience
Number of Years in Business

☐ Yes

☐ No

Vendor has a minimum of three years’ recent experience administering
standardized patient experience surveys as an organization within the
most recent five-year period (2019-2023).

☐ Yes

☐ No

Vendor has a minimum of three years’ recent experience conducting
large-scale mixed-mode (mail/telephone/internet) survey protocols in all
three modes within the most recent five-year period (2019-2023).

☐ Yes

☐ No

Vendor has recent experience* administering patient experience
surveys for vulnerable populations.

☐ Yes

☐ No

Vendor has a minimum of two years’ recent experience employing a
statistical sampling process within the most recent five-year period
(2019-2023).

☐ Yes

☐ No

Vendor has recent experience* submitting patient experience survey
data to an external third-party organization.

☐ Yes

☐ No

Vendor has recent experience complying with CMS-sponsored survey
protocols.

☐ Yes

☐ No

Vendor has been in business for a minimum of four years.

Survey Experience*

*Experience with polling questions, qualitative data collection, surveys that did not use statistical
sampling methods, or Interactive-Voice Response (IVR) surveys is not considered relevant experience
for approval.

In reviewing applications, CMS will consider the applicant’s recent experience on other CMSsponsored surveys as a vendor. Experience with polling questions, qualitative data collection,
surveys that did not use statistical sampling methods, or Interactive-Voice Response (IVR)
surveys are not considered relevant experience for approval.

Recent experience on CMS-Sponsored Surveys
CMS has approved the applicant as a vendor to implement other
CMS-sponsored or CAHPS surveys.

☐ Yes

☐ No

Complete
table below

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In the table below, provide details of at least five (but not more than 10) recent CMS-sponsored
standardized patient experience surveys your organization conducted within the last five-year
period (2019-2023). For mixed-mode survey administrations, indicate in the Mode of Survey
Administration column the specific mixed modes used (e.g., mail and internet).
Survey
name,
type,
contract
number

Average sample
size (and
response rate %)
per data
collection period

Data
collection
period
(Start and
end dates)

Number of
contracted
clients

Mode of survey
administration
(Mixed mode, mailonly, telephoneonly, internet-only)

Language(s)
administered

Number of
years
administering
survey

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Experience with Survey Administration in Multiple Languages
Vendor has recent experience administering mail, telephone, and
internet surveys in English and Spanish.

☐ Yes

☐ No

Is your organization seeking CMS approval to administer the QHP
Enrollee Survey in Chinese?

☐ Yes

☐ No

☐ Yes

☐ No

If applying to administer the QHP Enrollee Survey in Chinese:
Vendor has recent experience administering mail surveys in
Simplified Chinese and telephone surveys in Mandarin.

Explanation
Please explain any “No” responses to the above Relevant Survey Experience requirements.
Indicate the requirement(s) to which the explanation applies:

Requirement

Explanation

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2. Organizational Survey Capacity
Anticipated Clients for 2024 Survey Administration
Do you have any anticipated clients for 2024 survey administration?

☐ Yes

☐ No

Vendor has sufficient physical and personnel resources to administer
large-scale outgoing and incoming mail surveys, perform telephone
interviews using an electronic telephone interviewing system, and
administer the internet survey during the survey fielding period (e.g.,
February to May).

☐ Yes

☐ No

Vendor conducts all survey-related activities within the Continental United
States, Hawaii, Alaska, and U.S. Territories. This requirement applies to
all staff and subcontractors.

☐ Yes

☐ No

Vendor has the capacity to adhere to requirements specified in the 2024
Technical Specifications.

☐ Yes

☐ No

☐ Yes

☐ No

Vendor has a designated Mail Survey Supervisor with a minimum of one
year’s previous experience managing large-scale mail survey projects.

☐ Yes

☐ No

Vendor has a designated Telephone Center Survey Supervisor with a
minimum of one year’s previous experience managing large-scale
telephone interviewing projects.

☐ Yes

☐ No

Vendor has a designated Internet Survey Supervisor with a minimum of
one year’s previous experience managing large-scale internet survey
projects.

☐ Yes

☐ No

Vendor has a designated Sampling Manager, directly employed by the
vendor (i.e., not a subcontractor), with a minimum of one year’s previous
experience with sample frame development and sample selection.

☐ Yes

☐ No

If your organization anticipates clients for 2024 survey administration,
please specify estimated number of clients:

Capacity to Handle Estimated Workload

Personnel
Vendor has designated a Project Manager (PM) who oversees all survey
operations. The PM’s Curriculum Vitae (CV) shows evidence of:
• at least three years of experience overseeing all functional aspects
of survey operations including mail, telephone, internet, data file
preparation, and data security;
• strong background in survey research and methodology; and
• previous experience leading mixed-mode administration.
Note: PM must be the vendor’s direct employee, not a subcontractor.

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Vendor has designated Information System personnel (i.e.,
programmers) responsible for data submission who are directly employed
by the vendor (i.e., not a subcontractor) and have a minimum of one
year’s previous experience preparing and submitting data files in a
specified format to external third-party organization(s).

☐ Yes

☐ No

Vendor has appropriate organizational back-up staff for coverage of key
staff, in terms of sufficiency and experience.

☐ Yes

☐ No

☐ Yes

☐ No

☐ Yes

☐ No

Vendor has the capacity to reproduce and mail questionnaires, cover
letters and reminder letters at the vendor’s or subcontractor’s official
business location, as outlined in the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to process (e.g., scan or key enter) incoming
paper surveys at the vendor’s or designated subcontractor’s official
business location, as outlined in the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to program electronic telephone interview
systems in accordance with specifications provided and to conduct
telephone interviews using an electronic telephone interviewing system at
the vendor’s or subcontractor’s official business location, as outlined in
the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to produce and program the internet survey
instrument and all required emails in-house.

☐ Yes

☐ No

Vendor has the capacity to produce a mobile-ready version of the internet
survey in-house.

☐ Yes

☐ No

System Resources
Vendor’s commercial physical plant and system resources meet CMS
specifications and accommodate the volume of surveys being
administered. Note: All system resources are subject to oversight
activities, including onsite visits to physical locations and remote quality
oversight activities.
Vendor and its designated subcontractors (if applicable) conduct
business operations and all survey-related work, including mail and
internet survey administration and telephone interviewing, at the vendor’s
or approved subcontractor’s official business location. Home-based
places of work (e.g., residences) and virtual organizations will not be
considered without CMS approval.
Note: Vendors seeking an exception to this rule must submit an
exception request following receipt of confirmation of conditional approval
status. The exception request must indicate the reason for the exception
and the potential impact it might have on survey administration, data
management, and data security.

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Vendor can manage concurrent survey projects while maintaining highquality survey data and response rates.

☐ Yes

☐ No

Vendor has an electronic survey management system that tracks fielded
surveys through each stage of the protocol via random, unique deidentified enrollee identification numbers and interim disposition codes.
The electronic survey management system prevents duplicative records.

☐ Yes

☐ No

Vendor has the capacity to provide regular progress reports to QHP
issuers, within guidelines specified by CMS.

☐ Yes

☐ No

Vendor maintains a secure work environment for receiving, processing,
and storing hardcopy and electronic versions of questionnaires and
sample files that protects the confidentiality of survey response data and
Personally Identifiable Information (PII).

☐ Yes

☐ No

Vendor has the resources to prepare, accommodate, and plan for onsite
or remote visits from CMS or the CMS-sponsored Project Team for
quality oversight purposes.

☐ Yes

☐ No

Vendor can print, assemble, and mail survey materials in accordance
with the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor can program the electronic telephone interviewing system in
accordance with the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor can produce and program the internet survey instrument in
accordance with the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor can comply with all quality oversight requirements described in
the 2024 Technical Specifications. This includes the submission of
sample mail materials, sample telephone scripts and interviewer screen
shots, and an internet survey test link and test emails to the Project Team
for review and approval prior to survey administration.

☐ Yes

☐ No

Vendor has a demonstrated ability to collect and accurately process
survey data through all phases of survey administration.

☐ Yes

☐ No

Vendor has demonstrated experience identifying and contacting
nonrespondents for mail and telephone follow-up.

☐ Yes

☐ No

Vendor has the capacity to adhere to the survey administration timeline.

☐ Yes

☐ No

☐ Yes

☐ No

☐ Yes

☐ No

Mixed-Mode Administration

Vendor has experience using commercial software and resources to
verify that addresses and telephone numbers are updated and correct for
all sampled enrollees.
Vendor has the capability to administer the survey in English and
Spanish (and Chinese, if applicable).

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Vendor can assign appropriate disposition codes to each sampled
enrollee to indicate final survey status.

☐ Yes

☐ No

Vendor’s mail and internet survey administration activities and telephone
interviews are not conducted from any residences (i.e., no remote, homebased, or virtual work) without approval from CMS. Vendors seeking to
utilize remote operations must submit an exception request following
confirmation of conditional approval status. CMS may permit remote,
home-based, or virtual mail/internet survey administration and/or
telephone interviewing assuming that vendors can demonstrate they
satisfy the criteria specified by CMS.

☐ Yes

☐ No

Vendor has consistent experience in the five most recent years (20192023) selecting random samples based on specific eligibility criteria.

☐ Yes

☐ No

Vendor has documentation of its statistical approach to drawing a sample
and can demonstrate its ability to work with QHP issuer(s) to
electronically obtain sample frame(s) for sampling within a specified time
frame.

☐ Yes

☐ No

Vendor will adhere to all sampling procedures specified in the 2024
Technical Specifications, including conducting quality checks on sample
frame file(s) to verify accuracy and completeness of sample frame
information and processes.

☐ Yes

☐ No

Vendors will conduct the sampling process in-house and will not
subcontract this activity.

☐ Yes

☐ No

Vendor has the capability to scan or key enter data per protocols detailed
in the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor has the capacity to follow all data preparation and submission
rules specified in the 2024 Technical Specifications, including verifying
data are de-identified and contain no duplicate cases.

☐ Yes

☐ No

Vendor can register an account in CMS’s Identity Management (IDM)
system and submit data electronically to the designated website in the
format specified in the 2024 Technical Specifications.

☐ Yes

☐ No

Vendor will execute Business Associate Agreement(s) with QHP
issuer(s) and receive annual authorization from QHP issuer(s) to collect
and submit data to CMS on their behalf.

☐ Yes

☐ No

Vendor will work with the Project Team to resolve data and data file
submission problems within the specified timeframe.

☐ Yes

☐ No

Sampling Experience

Data Submission

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Data Security and Retention
Vendor maintains established electronic security procedures related to
access levels, passwords, and firewalls as required by the Health
Insurance Portability and Accountability Act (HIPAA) to protect against
unauthorized access to electronic files.

☐ Yes

☐ No

Vendor performs daily data backup and offsite redundancy procedures
that safeguard system data adequately.

☐ Yes

☐ No

Vendor develops a disaster recovery plan for conducting ongoing
business operations in the event of a natural or human-related disaster
that complies with relevant emergency preparedness guidelines.

☐ Yes

☐ No

Vendor has the capacity to use required encryption protocols, as
applicable, to transmit data files. Note: CMS-defined PII must be
transmitted securely (e.g., encrypted file via email, data portal, or SFTP).

☐ Yes

☐ No

Vendor has established procedures for identifying, handling, and
reporting breaches of confidential data.

☐ Yes

☐ No

Vendor will prepare and submit data via secure, HIPAA compliant
methods.

☐ Yes

☐ No

Vendor has the capacity to retain and easily retrieve all data files for a
minimum of three years.

☐ Yes

☐ No

Vendor has the capacity to store returned paper questionnaires in a
secure and environmentally safe location, either onsite or using an offsite
contractor.

☐ Yes

☐ No

Vendor has the capacity to securely destroy QHP Enrollee Surveyrelated data files after a minimum of three years, or as otherwise
specified by CMS.

☐ Yes

☐ No

Vendor has the capacity to store data files (paper and/or electronic)
securely and confidentially in accordance with specified requirements.

☐ Yes

☐ No

Vendor has the capacity and resources to ensure data confidentiality for
sampled enrollee PII and survey responses during each phase of the
survey process.

☐ Yes

☐ No

Vendor will obtain signed confidentiality agreements from staff and
subcontractors.

☐ Yes

☐ No

Vendor has the capacity and resources to comply with all applicable
HIPAA Security and Privacy Rules, as well as Protected Health
Information (PHI) and PII protocols in conducting all survey
administration and data collection activities.

☐ Yes

☐ No

Confidentiality

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Technical Assistance/Customer Support
Vendor has the capacity to establish toll-free customer support telephone
lines with a live operator during regular vendor business hours and a
survey-specific customer support email address to accommodate
inquiries received in both English and Spanish throughout the duration of
survey fielding.

☐ Yes

☐ No

If administering the survey in Chinese, vendor has the capacity and
resources to accommodate telephone inquiries from Chinese-speaking
survey participants.

☐ Yes

☐ No

Explanation
Please explain any “No” responses to the above Organizational Survey Capacity requirements.
Indicate the requirement(s) to which the explanation applies:

Requirement

Explanation

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3. Quality Control Procedures
Demonstrated Quality Control Procedures
Vendor has the capacity to establish and document quality control
procedures for all phases of survey implementation, as specified in the 2024
Technical Specifications, including:
•

Internal staff training;

•

Printing, mailing and recording receipt of surveys;

•

Telephone administration of surveys (electronic telephone
interviewing system);

•

Internet administration of surveys;

•

Scanning and coding of survey data;

•

Monitoring subcontractors (if applicable);

•

Preparing final data files for submission; and

•

All other functions and processes that affect the administration of the
QHP Enrollee Survey.

☐ Yes

☐ No

Vendor has the capacity to develop and submit an annual Quality
Assurance Plan (QAP) for administration in accordance with the 2024
Technical Specifications. The QAP provides written evidence of the
processes used to collect and process survey data accurately through all
phases of fielding.

☐ Yes

☐ No

Physical business premises on which the vendor conducts major survey
operations are amenable to onsite and/or remote visits by CMS and the
CMS-sponsored Project Team, as specified in the 2024 Technical
Specifications.

☐ Yes

☐ No

Explanation
Please explain any “No” responses to the above Quality Control Procedures requirements.
Indicate the requirement(s) to which the explanation applies:

Requirement

Explanation

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III.
Name

List of Key Project Staff
Role

Years with
Organization

Email Address

Telephone
Number

1.
2.
3.
4.
5.

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IV.

Subcontractors

Subcontractors
Check here if your organization does not plan to use subcontractors for
2024 QHP Enrollee Survey administration.

Response
☐

Please complete the following section for each subcontractor your organization plans to use for
2024 QHP Enrollee Survey administration. The following requirements must be met:

•
•

•
•

Each subcontractor must meet the criteria outlined for the survey administration activity
that it will conduct.
The subcontracting of printing, outgoing mail processing, data entry and scanning, and
telephone interviewing and/or customer support by a vendor is limited to a reasonable
number of subcontractors based on the vendor’s estimated number of surveyed
enrollees, and subject to CMS review.
The vendor may not subcontract sample file generation, email or internet survey
administration, or data file preparation and submission.
All subcontractors are subject to CMS approval.

Subcontractor Name(s), Role(s) and Experience
Subcontractor 1
1. Subcontractor organization name
2. Mailing address
3. Telephone number
4. Number of years in business
5. Number of years subcontractor has worked
with your organization

6. Survey administration role(s)
7. Experience related to survey administration

role(s), including names of relevant projects

8. Primary contact person

(First name, Last name; Title; Credential(s))

9. Primary contact telephone number
10. Primary contact email address

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Subcontractor 2
1. Subcontractor organization name
2. Mailing address
3. Telephone number
4. Number of years in business
5. Number of years subcontractor has worked
with your organization

6. Survey administration role(s)
7. Experience related to survey administration

role(s), including names of relevant projects

8. Primary contact person

(First name, Last name; Title; Credential(s))

9. Primary contact telephone number
10. Primary contact email address
Subcontractor 3
1. Subcontractor organization name
2. Mailing address
3. Telephone number
4. Number of years in business
5. Number of years subcontractor has worked
with your organization

6. Survey administration role(s)
7. Experience related to survey administration

role(s), including names of relevant projects

8. Primary contact person

(First name, Last name; Title; Credential(s))

9. Primary contact telephone number
10. Primary contact email address

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Subcontractor 4
1. Subcontractor organization name
2. Mailing address
3. Telephone number
4. Number of years in business
5. Number of years subcontractor has worked
with your organization

6. Survey administration role(s)
7. Experience related to survey administration

role(s), including names of relevant projects

8. Primary contact person

(First name, Last name; Title; Credential(s))

9. Primary contact telephone number
10. Primary contact email address

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V.

Curriculum Vitae

Please submit a CV for all identified key vendor staff and subcontractor staff, if applicable, via
email to the Project Team at qhp_survey@air.org. Please ensure subject line in email reads,
“[Vendor Name] Key Staff CV Submission.”

VI.

Participation Rules

Any vendor participating in 2024 QHP Enrollee Survey administration must adhere to the
following Participation Rules. To be eligible, the organization must:
1. Meet the 2024 QHP Enrollee Survey Minimum Business Requirements (MBR).
2. Participate in a teleconference call with the Project Team (as determined by CMS) to
discuss relevant survey experience, organizational survey capability and capacity, quality
control procedures, and role of subcontractors (if applicable).
3. Participate in and successfully complete QHP Enrollee Survey Vendor Training and all
subsequent QHP Enrollee Survey Vendor update trainings. At a minimum, the
organization’s Project Manager, Mail Survey Supervisor, Telephone Survey Supervisor,
Internet Survey Supervisor, and Sampling Manager must attend training as representatives
of the organization. It is strongly recommended that the Project Director and any additional
key staff responsible for programming, data coding, and file preparation also attend training.
Subcontractor attendance is optional.
4. Review and comply with the 2024 Technical Specifications and any policy updates.
5. Develop and submit a vendor Quality Assurance Plan as specified by the deadline
determined by CMS. In addition, submit materials relevant to the survey administration (as
determined by CMS), including mailing materials (e.g., cover letters, questionnaires,
reminder letters and envelopes), telephone scripts and the internet survey instrument.
6. Participate and cooperate (including subcontractors) in all oversight activities conducted by
the Project Team, including but not limited to survey material review, remote site visits,
seeded mailings, telephone interview monitoring, data review, and other oversight activities
as determined by CMS.
7. Acknowledge that mail and internet survey administration activities and telephone interviews
are not to be conducted from any residences (i.e., no remote, home-based, or virtual work)
under normal business operations.
Note: Vendors seeking an exception to this rule must submit an exception request indicating
the reason for the exception and the potential impact it might have on survey administration,
data management, and data security.

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8. Comply with all rules and regulations pertaining to PII and PHI per the HIPAA.
9. Submit an interim survey data file to CMS, as determined by CMS.
10. Submit data on time, as specified by the deadline determined by CMS.
11. Attest to the accuracy of the organization’s data collection (as determined by CMS) and
follow the guidelines set forth in the 2024 Technical Specifications.
12. Notify the Project Team of any discrepancies or variations from standard QHP Enrollee
Survey protocols that occur as the discrepancy is identified. The vendor must complete and
submit a Discrepancy Report (in the format and manner specified by CMS) within one
business day of becoming aware of the discrepancy. Vendors must notify QHP issuer clients
whenever a Discrepancy Report is submitted to the Project Team regarding their reporting
unit(s), as applicable.
13. Attest that the vendor is organizationally independent from the QHP issuer client; the vendor
must not administer the QHP Enrollee Survey or produce survey results to meet CMS
requirements for any QHP client issuer that controls, is controlled by, or is under common
control with the vendor.
14. Acknowledge that contracting with and successfully administering the QHP Enrollee Survey

on behalf of at least one QHP issuer within 24 months of receiving initial approval status is a
requirement for continued approval status. A vendor must continue to field the survey for at
least one QHP issuer during every 24-month increment following the initial 24-month period.

15. Acknowledge that CMS may, at its sole discretion, terminate or discontinue the “approved”
status of a vendor. CMS may exercise these actions at any point during survey
administration.
16. Acknowledge that review of and agreement with the Rules of Participation is necessary for
participation.

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VII. Applicant Organization Qualification and Acceptance
I certify that:

Authorized Representative

•

I have reviewed and agree to meet the
Name:
Rules of Participation for participating in the
2024 QHP Enrollee Survey.
Title:

•

The statements herein are true, complete,
Organization:
and accurate to the best of my knowledge,
and I accept the obligation to comply with Date:
the 2024 QHP Enrollee Survey MBR.
Signature:

For assistance, please contact the Project Team by email at qhp_survey@air.org.

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