Form CMS-10555 SHOP Notices Agents-Brokers Survey

Attachment 1.SHOP Survey – Agents & Brokers

OMB #: 0938-

Expiration Date:

Learning about the SHOP Marketplace:

Enrollment:

How satisfied are you with the instructions in the SHOP Marketplace enrollment application?

(Scale of 1 to 5)

1 – Extremely dissatisfied -> 2 – Somewhat dissatisfied -> 3 – Neutral -> 4 – Somewhat satisfied -> 5 – Extremely satisfied

SHOP Call Center:

Have you contacted the SHOP Call Center for help with the SHOP Marketplace? Yes/No [Ask if Yes] How satisfied were you with your experience with the SHOP Call Center?

(Scale of 1 to 5) 1 – Extremely dissatisfied -> 2 – Somewhat dissatisfied -> 3 – Neutral -> 4 – Somewhat satisfied -> 5 – Extremely

satisfied

SHOP Agent/Broker Portal

How would you rate your overall experience with the SHOP Marketplace Agent/Broker Portal? The Agent/Broker Portal is what you use online to help with SHOP Marketplace enrollment and account maintenance functions.

(Scale of 1 to 5)

1 – Extremely dissatisfied -> 2 – Somewhat dissatisfied -> 3 – Neutral -> 4 – Somewhat satisfied -> 5 – Extremely satisfied

SHOP payments:

Customer demographics (optional):

Resources/recommendations:

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