Form #2 Form #2 Establishment Questionnaire

OMB No. 0935-0110: Approval Expires

2006 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY

(Please correct any errors in name, address, and ZIP Code.
Enter number and street if not shown.)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

RETURN TO

U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001
Fax to 1–800–447–4613

PLEASE RETURN ENTIRE PACKAGE WITHIN

PLEASE DO NOT REMOVE THIS COVER SHEET
FORM

MEPS-10

(4-20-2007)

OR

INSTRUCTIONS
1. Please report for the location identified on the cover sheet, unless
otherwise specified.
2. Please report data for the year 2006.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the Definition Sheet
included with this package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a completed copy of this form for your records.
7. If you have any questions or need assistance in completing the
questionnaire, please call

Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, per establishment, to complete the basic questionnaire. Establishments with
more than one health plan will take an additional 10 minutes per plan, on average, up to the maximum of four plans to be
reported. In addition, we estimate that it will take 15 minutes to review the instructions and locate the requested information.
You may send any comments regarding this burden estimate or any other aspect of the collection of information, including
suggestions for reducing burden, to the following address: Director, Center for Financing, Access and Cost Trends, Paperwork
Reduction Project 0935-0110, Agency for Healthcare Research and Quality, Room 5030, 540 Gaither Road, Rockville, MD
20850. Please do not mail questionnaires to this address as it will delay data processing.

Page 2

FORM MEPS-10 (4-20-2007)

Section A – NUMBER OF PLANS
Respond for ACTIVE employees only.

1.

Did your organization make available or contribute
to the cost of any health insurance plans for its
ACTIVE employees at this location in 2006?

001

2

For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.

2.

How many different health insurance plan choices
did your organization make available or contribute
to for its ACTIVE employees at this location during
the 2006 plan year?

1

Yes – Continue with Question 2
No – SKIP to Section B

003

SKIP to Page 4, Section C

Do not count single service plans (optional plans) such as
dental or vision.
Plans offered by the same insurance company which offer:
• Single, employee-plus-one, and family coverage
providing the same level of benefits count as one
plan.
• High and standard options count as two plans.
• An HMO and a conventional plan count as two plans.

Section B – HEALTH INSURANCE NOT OFFERED
Complete only if health insurance was NOT offered during
2006; otherwise, SKIP to Page 4, Section C.

1.

2.

Did your organization offer any health insurance as a
benefit to its employees at this location between
January 1, 2002 and December 31, 2006?
What was the last year your organization offered
health insurance coverage to its employees at this
location?

031

1
2

Yes – Continue with Question 2
No – SKIP to Page 4, Section C

032

Last year offered
Continue with Page 4, Section C

FORM MEPS-10 (4-20-2007)

Page 3

Section C – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include officers, owners, part-time, temporary and
seasonal employees.
Exclude former employees, leased or contract
workers and retirees.

1.

What was the total number of employees your
organization had at ALL locations for a
TYPICAL pay period in 2006?

034

Employees at all locations

Complete questions 2–7 for THE LOCATION listed on
the cover sheet.

2a.

How many employees were on your organization’s
payroll AT THIS LOCATION for a TYPICAL pay
period in 2006?

200

All employees at this location
If your organization did not offer health insurance in
2006, SKIP to Question 3a.

b.

c.

3a.

How many of these employees were ELIGIBLE for at
least one health plan through your organization?

201

How many of these employees were ENROLLED in
ANY health plan through your organization?

202

For the same TYPICAL pay period in 2006, how
many of the employees reported in C2a worked
part-time?

203

Eligible employees

Enrolled employees

Part-time employees
If your organization did not offer health insurance in
2006, SKIP to Question 5.

b.

c.

4.

How many of these part-time employees were
ELIGIBLE for at least one health plan through your
organization?

204

How many of these part-time employees were
ENROLLED in ANY health plan through your
organization?

205

Did your organization offer health insurance to its
temporary or seasonal employees at this location
in 2006?

564

Eligible part-time employees

Enrolled part-time employees

Mark (X) only one.

5.

6.

Is the information you provided in questions 2 and
3 above for the location listed on the cover sheet
OR did you provide information for multiple
locations?

550

If your organization offered health insurance,
how many hours per week must an employee
work to be eligible for health insurance?

626

1

Yes

2

No

4

No temporary or seasonal employees

3

Don’t know

1

Information for specified location

2

Information for multiple locations

If your organization did not offer health insurance in
2006, SKIP to Page 5, Question 7a.
Hours worked per week to
be eligible
Continue with Page 5, Section C

Page 4

FORM MEPS-10 (4-20-2007)

Section C – EMPLOYMENT CHARACTERISTICS – Continued
Provide information for a TYPICAL pay period in 2006.
Estimates are acceptable.
The following workforce characteristics are used to group
similar organizations together for analytical purposes.
If none, enter "0".

7a.
b.
c.
d.

Approximately what percentage of the employees
at this location were women?

016

Approximately what percentage of the employees
at this location were 50 years old or older?

017

Approximately what percentage of the employees
at this location were union members?

018

For the employees at this location in 2006,
approximately what percentage earned –

022

Less than $10.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $21,840 a year or less

023

Between $10.50 and $23.50 per hour? . . . . . . . . . .
Approximately $21,840 to $48,880 a year

024

More than $23.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $48,880 a year or more

FORM MEPS-10 (4-20-2007)

%
%
%

%
%
%

Women employees

Employees 50 years old or older

Union members

Earned less than $10.50 per hour
Earned between $10.50 and $23.50 per hour
Earned more than $23.50 per hour
Continue with Page 6, Section D

Page 5

Section D – BUSINESS CHARACTERISTICS

1a.

Which of the following fringe benefits did your
organization offer its employees at this location
in 2006?
050
051
052
053
054

b.

Did your organization offer any of these
tax-advantaged benefits to its employees at this
location in 2006?
See the Definition Sheet included with this package for an
explanation of these benefits.

If your organization operates at more than one location,
enter the number of years the parent company has been in
business.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

Employee contributions to health
insurance made on a pre-tax basis

056

Flexible SPENDING Accounts (FSA)
For healthcare
Flexible Benefits Plans
Full cafeteria plan that offers
employees a set of benefits
from which to choose.

057

Approximately how many years has your
organization been in business?

.
.
.
.
.

627

These benefits are also known as Section 125 Cafeteria plans.

2.

Paid vacation . . . . . . . .
Paid sick leave . . . . . . .
Life insurance . . . . . . . .
Disability insurance . . . .
Retirement/pension plans

588

1
2
3

Less than 1 year
1–2 years
3–4 years

4
5
6

Yes

No

Don’t
know

(1)

(2)

(3)

Yes

No

Don’t
know

(1)

(2)

(3)

.
.
.
.
.

5–9 years
10–19 years
20 years or more

If your organization DID offer health insurance coverage to its
employees in 2006, continue to Page 7, Section E.
If your organization DID NOT offer health insurance coverage to
its employees in 2006, SKIP to Page 8, Section F.

Page 6

FORM MEPS-10 (4-20-2007)

Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS

1a.

Which of the listed optional coverage services, if
any, did your organization offer to its ACTIVE
employees at this location in 2006 at a premium
SEPARATE from the comprehensive health plan
premium?

}

195

Dental
Vision
Prescription drugs
Long-term care

562

No optional coverage – SKIP to Question 2a

192
193
194

Continue with Question 1b

Report single service insurance plans only.
Do not include single services covered under a
comprehensive health plan.
Long-term care insurance helps cover the cost of institutional
and home care required by the chronically ill or disabled.
Mark (X) all that apply.

b.

What was the total amount paid for optional
coverage for all ACTIVE employees AT THIS
LOCATION in 2006?

196

$

b.

For 2006, did your organization impose a waiting
period before new employees could be covered by
health insurance?

197

For 2006, what was the TYPICAL waiting period?

198

Mark (X) only one.

,

,

. 0 0

Optional coverage cost

Include both employer and employee contributions.

2a.

,

1
2

1
2
5
3
4

Yes – Continue with Question 2b
No – SKIP to Page 8, Section F
Less than 2 weeks
2 weeks to less than 1 month
Until the first day of the next month
1–3 months
More than 3 months
Continue with Page 8, Section F

FORM MEPS-10 (4-20-2007)

Page 7

Section F – RETIREE HEALTH COVERAGE CHARACTERISTICS
Please complete questions 1–5 for ALL LOCATIONS.
Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws. See the Definition Sheet
included with this package for an explanation of these terms.

1.

Did your organization provide health insurance
coverage to any person who retired ON OR
BEFORE December 31, 2006, or to any of their
survivors?

551

Yes – Continue with Question 2
No
SKIP to Page 10, Section G
Don’t know

1

}

2
3

If COBRA was the only coverage offered, mark "No."

2.

In 2006, what was the total number of retirees
enrolled in health insurance through your
organization at all of its locations?

513

Total retirees enrolled

UNDER 65 YEARS OF AGE
Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws.
If this was a Self-Insured Plan, report the premium
equivalent.

3a.

Were any of the enrolled retirees, reported in
Question 2, under 65 years of age?

628

b.

What was the TOTAL number of retirees under 65
years of age enrolled in health insurance through
your organization at all of its locations in 2006?

572

c.

What percentage of these retirees were
ENROLLED in SINGLE coverage?

573

d.

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE coverage?

e.

f.

g.

Yes – Continue with Question 3b
No – SKIP to Page 9, Question 4a

1
2

Total retirees under 65
enrolled in health insurance

under 65 enrolled
% Retirees
in single coverage

574

For this same plan, what was the TOTAL monthly
premium for this typical retiree with SINGLE
coverage?

575

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
For retirees, if premium varied by family size, report for a family
of two.

576

For this same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?

577

$

,

. 0 0

Employer contribution
for single premium

$

,

. 0 0

Total single
premium

$

,

. 0 0

Employer contribution
for family premium

$

,

. 0 0

Total family
premium

Continue with Page 9, Question 4a

Page 8

FORM MEPS-10 (4-20-2007)

Section F – RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
AGE 65 YEARS OR OVER
Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws.
If this was a Self-Insured Plan, report the premium
equivalent.

4a.

b.

Were any of the enrolled retirees, reported in
Question 2, 65 years of age or over?

What was the TOTAL number of retirees 65 years
of age or over enrolled in health insurance through
your organization at all of its locations in 2006?

c.

What percentage of these retirees were
ENROLLED in SINGLE coverage?

d.

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE coverage?

e.

f.

g.

629

Yes – Continue with Question 4b
No – SKIP to Question 5a

1
2

578

Total retirees 65 or over
enrolled in health insurance
579

65 or over enrolled in single
% Retirees
coverage

580

For this same plan, what was the TOTAL monthly
premium for this typical retiree with
SINGLE coverage?

581

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
For retirees, if premium varied by family size, report for a family
of two.

582

For this same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?

583

$

,

. 0 0

Employer contribution
for single premium

$

,

. 0 0

Total single
premium

$

,

. 0 0

Employer contribution
for family premium

$

,

. 0 0

Total family
premium

NEW RETIREES
For questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your organization in 2006.

Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws.

5a.

Did your organization offer health insurance to any
NEW RETIREES?

630

1
2
3

b.

Were NEW RETIREES under 65 years of age eligible
for health insurance?

631

1
2
3

c.

Were NEW RETIREES 65 years of age or over eligible
for health insurance?

632

1
2
3

FORM MEPS-10 (4-20-2007)

Yes – Continue with Question 5b
No
SKIP to Page 10, Section G
Don’t know

}

Yes
No
Don’t know
Yes
No
Don’t know
Continue with Page 10, Section G
Page 9

500

Remarks

Section G – PERSON COMPLETING THIS QUESTIONNAIRE

*** PLEASE NOTE ***
If your organization offered health insurance, please complete Section G
and an attached MEPS-10(S), Plan Information Questionnaire, for each
plan offered up to four.
If your organization DID NOT offer health insurance, please complete
Section G and END the form.

212

213

Name (Please print)

Title

Signature

214

M
215

Telephone number

(
Page 10

)

220

Extension

216

FAX number

(

217

Date (Month/Day/Year)
M

D

D

Y

Y

Y

Y

E-Mail address

)

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

FORM MEPS-10 (4-20-2007)

OMB No. 0935-0110: Approval Expires

2006 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY
Government Questionnaire

(Please correct any errors in name, address, and ZIP Code.
Enter number and street if not shown.)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

RETURN TO

U.S. Census Bureau
Governments Division – MEPS
4600 Silver Hill Road, Stop 6800
Washington, DC 20233-6800
OR FAX to 1–888–288–0305

PLEASE RETURN ENTIRE PACKAGE WITHIN

PLEASE DO NOT REMOVE THIS COVER SHEET
FORM

MEPS-11C(F) (4-24-2007)

INSTRUCTIONS
1. Please report for the government unit identified on the cover
sheet.
2. Report data for the year 2006.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the Definition Sheet
included with this package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a copy of this completed form for your records.
7. In addition to the completed questionnaire, please include a copy
of each of your health insurance plan brochures describing
the benefits offered, or a copy of the benefits sheet summarizing the
benefits offered by each of your plans.
8. If you have any questions or need assistance in completing the
questionnaire, please call 1-888-206-5068.

We are conducting this study under the authority of Section 913 of the Public Health
Service Act (Title 42, United States Code (U.S.C.), Section 299b-2). Sections 924c and 308d
of that Act (42 U.S.C. Section 299c-3(c) and 42 U.S.C. Section 242m, respectively) ensure
that the information you report will be released only to authorized staff of the U.S. Census
Bureau, the Agency for Healthcare Research and Quality, and their authorized researchers
and contractors.

Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, to complete the basic questionnaire. If you offered more than one plan, we expect
it will take an additional 10 minutes per plan, on average. In addition, we estimate that it will take 15 minutes to review the
instructions and locate the requested information. You may send any comments regarding this burden estimate or any other aspect
of the collection of information, including suggestions for reducing burden, to the following address: Director, Center for Financing,
Access and Cost Trends, Paperwork Reduction Project 0935-0110, Agency for Healthcare Research and Quality, Room 5030, 540
Gaither Road, Rockville, MD 20850. Please do not mail questionnaires to this address as it will delay data processing.

FORM MEPS-11C(F) (4-24-2007)

Section A – NUMBER OF PLANS

1a.

Please respond for the government unit identified on the cover sheet.
Respond for ACTIVE employees only.
Did your government unit make available or
contribute to the cost of any health insurance plans
001
for its ACTIVE employees in 2006?

2

For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.

b.

How many different health insurance choices did
your government unit make available or contribute
to for its ACTIVE employees during the 2006 plan
year?

1

Yes – Continue with Question 1b
No – Complete contact information below then
SKIP to MEPS-11C(R), Section E, Question 2a

003

Number of health
plans offered

Plans offered by the same insurance company which offer:
●

●
●

Single, employee-plus-one, and family coverage
providing the same level of benefits count as ONE
plan.
High and standard options count as TWO plans.
An HMO and a conventional plan count as TWO
plans.

Do not count single service plans (optional plans)
such as dental or vision.

c.

Are health benefits brochures for those plans
available on a website?

671

1
2

Yes – Please provide website address below
No

COMMENTS
500

CONTACT INFORMATION – PERSON COMPLETING THIS QUESTIONNAIRE
212

213

Name (Please print)

670

Signature

Title

Brochure Website address

214

M
215

(

Telephone number

)

FORM MEPS-11C(F) (4-24-2007)

220

http: //
Extension 216 FAX number

(

217

E-Mail address

)

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

Date (Month/Day/Year)
M

D

D

Y

Y

Y

Y

OMB No. 0935-0110: Approval Expires

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

Medical Expenditure Panel Survey – Insurance Component

HEALTH INSURANCE COST STUDY
Government Unit Questionnaire

Section C – RETIREE HEALTH COVERAGE CHARACTERISTICS
Exclude any retirees that have coverage
through PHSA (COBRA) or State
Continuation-of-Benefits-Laws.
If this is a self-insured plan, report the premium
equivalent.
For an explanation of these terms, see the definition
sheet included with this package.

1.

551

Did your government unit or some other
government unit provide health insurance
coverage to any person who RETIRED from
your government unit ON OR BEFORE
December 31, 2006, or to any of their
survivors?

672

If PHSA (COBRA) was the only coverage offered,
mark "No".

551

1

Yes – This government unit – Continue with Question 2

4

Yes – Another government unit

Enter name of other government unit
Continue with Question 2 if information is available.
Otherwise Skip to Section D.
2
3

2.

In 2006, what was the TOTAL NUMBER of
retirees enrolled in health insurance
through your government unit?

No
Don’t know

}

SKIP to Section D.

513

Total retirees

CONTINUE WITH QUESTION 3a ON NEXT PAGE

FORM

MEPS-11C(R) (4-25-2007)

Section C – RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
Use the two columns below to report the information for EACH QUESTION by age category.
• The first column is the information for each question as it pertains to retirees UNDER 65 YEARS OF AGE.
• The second column is the information for each question as it pertains to retirees AGE 65 YEARS AND OVER.
Exclude any retirees that have coverage
through PHSA (COBRA) or State
Continuation-of-Benefits-Laws.

3a.
b.
c.
d.

e.

f.
g.

h.

i.

UNDER 65 YEARS OF AGE

Were any of the retirees with coverage,
reported in Question 2, under 65 years of
age or age 65 years or over?

628

What was the TOTAL number of
retirees, by age category, enrolled in
health insurance through your
government unit in 2006?
What percentage of those retirees, by
age category, were ENROLLED in
SINGLE coverage?

572

For the 2006 plan with the largest enrollment, how much did the GOVERNMENT
UNIT CONTRIBUTE, by age category,
toward the monthly plan premium for one
typical retiree with SINGLE coverage?
For that same plan, how much did this
typical RETIREE with SINGLE coverage
CONTRIBUTE, by age category, toward
his/her monthly plan premium?
For that same plan, what was the TOTAL
monthly premium, by age category, for this
typical retiree with SINGLE coverage?
For the 2006 plan with the largest enrollment, how much did the GOVERNMENT
UNIT CONTRIBUTE, by age category,
toward the monthly plan premium for one
typical retiree with FAMILY coverage?
For retirees, if premium varied by family size,
report for a family of two.
For that same plan, how much did this
typical RETIREE with FAMILY coverage
CONTRIBUTE, by age category, toward
his/her monthly plan premium?
For that same plan, what was the TOTAL
monthly premium, by age category, for this
typical retiree with FAMILY coverage?

1

Yes

2

No

AGE 65 YEARS OR OVER
629

1

Yes

2

No

578

Total under 65
573

Total 65 or over
579

% Percent enrolled

% Percent enrolled

in single

574

in single

580

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

651

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

$

,

. 0 0

653

575

581

576

652

582

654

577

583

NEW RETIREES

4a.
b.

For Questions 4a through 4c, NEW RETIREES
refers to persons who retired from your
government unit in 2006.
Exclude any retirees that have coverage
through PHSA (COBRA) or State
Continuation-of-Benefits-Laws.
Did your government unit offer health
insurance to any NEW RETIREES?
Were NEW RETIREES under 65 years of
age eligible for health insurance?

630

1
2
3

631

1
2
3

c.

Were NEW RETIREES 65 years of age or
over eligible for health insurance?

632

1
2
3

Page 2

Yes – Continue with Question 4b
No
SKIP to Section D
Don’t know

}

Yes
No
Don’t know
Yes
No
Don’t know
FORM MEPS-11C(R) (4-25-2007)

Section D – HEALTH COVERAGE CHARACTERISTICS

1a.

Which of the listed optional coverage services, if
any, did your government unit offer to its ACTIVE
employees in 2006 at a premium SEPARATE from
the comprehensive health plan premium?
Report single service insurance plans only.

195

Dental
Vision
Prescription drugs
Long-term care

Long-term care insurance helps cover the cost of institutional
and home care required by the chronically ill or disabled.

562

No optional coverage – SKIP to Section E

192
193
194

}

Continue with Question 1b

Mark (X) all that apply.
Do not include single services covered under a
comprehensive health plan.

b.

What was the total amount paid for OPTIONAL
COVERAGE for all ACTIVE employees at THIS
GOVERNMENT UNIT in 2006?

196

$

,

,

,

. 0 0

Optional coverage cost

Include both employee and government unit contribution.

Section E – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include part-time, temporary, and seasonal employees.

1a.

b.

2a.

How many ACTIVE employees were ELIGIBLE for
at least one health plan through your government
unit in 2006?
How many of those ACTIVE employees were
ENROLLED in ANY health plan through your
government unit?
Did your government unit have any PART-TIME
employees in 2006?

201

Eligible employees

202

Enrolled employees

563

1
2

If your government unit did not offer health
insurance in 2006, complete question 2a, then
SKIP to Section F.

b.

c.

3.

How many of those PART-TIME employees were
ELIGIBLE for at least one health plan through your
government unit?
How many of those PART-TIME employees were
ENROLLED in ANY health plan through your
government unit?
Did your government unit offer health insurance to
its TEMPORARY OR SEASONAL employees in 2006?

3

Eligible part-time employees
205

Enrolled part-time employees

564

Mark (X) only one.

1

4
3

If you offered health insurance, how many HOURS
PER WEEK must an employee work to be eligible
for health insurance?

}

204

2

4.

Yes – Continue with Question 2b
No
SKIP to Question 3
Don’t know

Yes
No
No temporary or seasonal employees
Don’t know

626

Hours worked per week to be eligible

If you have questions or need assistance,
call us toll-free at 1–888–206–5068.
FORM MEPS-11C(R) (4-25-2007)

Page 3

Section F – FRINGE BENEFITS CHARACTERISTICS

1.

2.

Which of the following fringe benefits did your
government unit offer to its employees in 2006?
050

Paid vacation . . . . . . . . . . . . . . . .

051

Paid sick leave . . . . . . . . . . . . . . .

052

Life insurance . . . . . . . . . . . . . . .

053

Disability insurance . . . . . . . . . . . .

054

Retirement/pension plans . . . . . . . .

Did your government unit offer any of these
tax-advantaged benefits to its employees in 2006?
See definition sheet included with this package for an
explanation of these benefits.

627

Employee contributions to health
insurance made on a pre-tax basis

These plans are also know as Section 125 Cafeteria Plans.

056

Flexible SPENDING account (FSA)
for healthcare
Flexible Benefits Plans
Full cafeteria plans that offer employees
a set of benefits from which to choose

057

Yes
(1)

No
(2)

Don’t
know
(3)

Yes
(1)

No
(2)

Don’t
know
(3)

Section G – EMPLOYEE CHARACTERISTICS
Provide information for a TYPICAL pay period in
2006.
Estimates are acceptable.
The following workforce characteristics are used to group
similar government units together for analytical purposes.
If none, enter "0".

1.
2.
3.
4.

016

Approximately what percentage of the employees
at this government unit were WOMEN?

%

Approximately what percentage of the employees
at this government unit were 50 YEARS OLD OR
OLDER?

017

Approximately what percentage of the employees
at this government unit were UNION MEMBERS?

018

For the employees at this GOVERNMENT UNIT in
2006, approximately what percentage EARNED –

022

Less than $10.50 per hour? . . . . . . . . . . . . . . . . .
Approximately $21,840 a year or less

023

Between $10.50 and $23.50 per hour? . . . . . . . . .
Approximately $21,840 to $48,880 a year

024

More than $23.50 per hour? . . . . . . . . . . . . . . . . .
Approximately $48,880 a year or more

%
%

%
%
%

Women employees

Employees 50 years old or older

Union members

Earned less than $10.50 per hour
Earned between $10.50 and $23.50 per hour
Earned more than $23.50 per hour

Thank you for your cooperation in completing this survey.
The U.S. Census Bureau appreciates your assistance.

Page 4

FORM MEPS-11C(R) (4-25-2007)

OMB No. 0935-0110: Approval Expires

2006 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY
Government Questionnaire

(Please correct any errors in name, address, and ZIP
Code. Enter number and street if not shown.)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

RETURN TO

U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001
Fax to 1–800–447–4613

PLEASE RETURN ENTIRE PACKAGE WITHIN

PLEASE DO NOT REMOVE THIS COVER SHEET
FORM

MEPS-11(F)

(4-24-2007)

OR

INSTRUCTIONS
1. Please report for the government unit identified on the cover sheet.
2. Please report data for the year 2006.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the Definition Sheet
included with this package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a completed copy of this form for your records.
7. If you have any questions or need assistance in completing the
questionnaire, please call 1-888-273-3878.

We are conducting this study under the authority of Section 913 of the Public Health Service Act
(Title 42, United States Code (U.S.C.), Section 299b-2). Sections 924c and 308d of that Act (42
U.S.C. Section 299c-3(c) and 42 U.S.C. Section 242m, respectively) ensure that the information you
report will be released only to authorized staff of the Census Bureau, the Agency for Healthcare
Research and Quality, and their authorized researchers and contractors.

Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, to complete the basic questionnaire. If you offered more than one plan, we
expect it will take an additional 10 minutes per plan, on average. In addition, we estimate that it will take 15 minutes to review
the instructions and locate the requested information. You may send any comments regarding this burden estimate or any other
aspect of the collection of information, including suggestions for reducing burden, to the following address: Director, Center for
Financing, Access and Cost Trends, Paperwork Reduction Project 0935-0110, Agency for Healthcare Research and Quality,
Room 5030, 540 Gaither Road, Rockville, MD 20850. Please do not mail questionnaires to this address as it will delay data
processing.

Page 2

FORM MEPS-11(F) (4-24-2007)

Section A – NUMBER OF PLANS

1a.

b.

Please respond for the government unit identified on the cover sheet unless otherwise specified.
Respond for ACTIVE employees only.
Did your government unit make available or
contribute to the cost of any health insurance plans
001
1
Yes – Continue with Question 1b
for its ACTIVE employees in 2006?
2
No – SKIP to MEPS-11(R), Section E, Question 2a
For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.
How many different health insurance choices did
your government unit make available or contribute
to for its ACTIVE employees during the 2006 plan
year?

003

Continue with Section B on MEPS-11(S)

Do not count single service plans (optional plans) such
as dental or vision.
Plans offered by the same insurance company which offer:
• Single, employee-plus-one, and family
coverage providing the same level of benefits
count as ONE plan.
• High and standard options count as TWO plans.
• An HMO and a conventional plan count as TWO
plans.
500

REMARKS

FORM MEPS-11(F) (4-24-2007)

Page 3

OMB No. 0935-0110: Approval Expires
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

Medical Expenditure Panel Survey – Insurance Component

HEALTH INSURANCE COST STUDY
Government Unit Questionnaire

Section C – RETIREE HEALTH COVERAGE CHARACTERISTICS
Exclude any retirees that have coverage through
PHSA (COBRA) or State Continuation-of-Benefits laws.
See the Definition Sheet included with this package for an
explanation of these terms.

1.

551

1

Yes – This government unit – Continue with Question 2

4

Yes – Another government unit

672

Did your government unit or some other
government unit provide health insurance coverage
to any person who retired from your government
unit ON OR BEFORE December 31, 2006, or to any
of their survivors?

Enter name of other government unit
Continue with Question 2 if information is available.
Otherwise SKIP to Page 3, Section D.

If PHSA (COBRA) was the only coverage offered mark "No".
551

No
Don’t know

2
3

2.

In 2006, what was the total number of retirees
enrolled in health insurance through your
government unit?

}

SKIP to Page 3, Section D.

513

Total retirees enrolled

UNDER 65 YEARS OF AGE
Exclude any retirees that have coverage through
PHSA (COBRA) or State Continuation-of-Benefits Laws.

3a.

If this was a self-insured plan, report the premium equivalent.
Were any of the enrolled retirees reported in
Question 2, under 65 years of age?

628

Yes – Continue with Question 3b
No – SKIP to Question 4a on Page 2

1
2

b.

What was the TOTAL number of retirees under
65 years of age enrolled in health insurance
through your government unit in 2006?

572

c.

What percentage of those retirees were
ENROLLED in SINGLE coverage?

573

Total retirees under 65
enrolled in health insurance

% Retirees under 65

enrolled in single coverage

FORM

d.

For a typical plan in 2006, how much did the
GOVERNMENT UNIT contribute toward the monthly
plan premium for one typical retiree with SINGLE
coverage?

e.

For that same plan, what was the TOTAL monthly
premium for this typical retiree with SINGLE
coverage?

,

. 0 0

Government
unit contribution
for single
premium

$

,

. 0 0

Total single
premium

$

,

. 0 0

Government
unit contribution
for family
premium

$

,

. 0 0

Total family
premium

575

f.

For a typical plan in 2006, how much did the
GOVERNMENT UNIT contribute toward the monthly
plan premium for one typical retiree with FAMILY
coverage?
For retirees, if premium varied by family size, report
for a family of two.

576

g.

For that same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?

577

MEPS-11(R) (4-26-2007)

$

574

Section C – RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
AGE 65 YEARS OR OVER
Exclude any retirees that have coverage through
PHSA (COBRA) or State Continuation-of-Benefits Laws.

4a.

Were any of the enrolled retirees reported in
Question 2, 65 years of age or over?

629

b.

What was the TOTAL number of retirees 65 years
or over enrolled in health insurance through your
government unit in 2006?

578

c.

What percentage of those retirees were
ENROLLED in SINGLE coverage?

579

Yes – Continue with Question 4b
No – SKIP to Question 5a

1
2

Total retirees 65 years or over
enrolled in health insurance

% Retirees 65 years or over enrolled in
single coverage

d.

For the 2006 plan with largest the enrollment, how
much did the GOVERNMENT UNIT contribute toward
the monthly plan premium for one typical retiree with
SINGLE coverage?

580

e.

For that same plan, what was the TOTAL monthly
premium for this typical retiree with SINGLE
coverage?

581

For the 2006 plan with the largest enrollment, how
much did the GOVERNMENT UNIT contribute toward
the monthly plan premium for one typical retiree with
FAMILY coverage?
For retirees, if premium varied by family size, report
for a family of two.

582

For that same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?

583

f.

g.

$

,

. 0 0

Government
unit contribution
for single
premium

$

,

. 0 0

Total single
premium

$

,

. 0 0

Government
unit contribution
for family
premium

$

,

. 0 0

Total family
premium

NEW RETIREES
Exclude any retirees that have coverage through
PHSA (COBRA) or State Continuation-of-Benefits Laws.
For Questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your government unit in 2006.

5a.

Did your government unit offer health insurance to
any NEW RETIREES?

630

1
2
3

b.

Were NEW RETIREES under 65 years of age
eligible for health insurance?

631

1
2
3

c.

Were NEW RETIREES 65 years of age or over
eligible for health insurance?

632

1
2
3

Page 2

Yes – Continue with Question 5b
No
SKIP to Page 3, Section D
Don’t know

}

Yes
No
Don’t know
Yes
No
Don’t know

FORM MEPS-11(R) (4-26-2007)

Section D – HEALTH COVERAGE CHARACTERISTICS

1a.

b.

2a.
b.

Which of the listed optional coverage services, if
any, did your government unit offer to its ACTIVE
employees in 2006 at a premium SEPARATE from
the comprehensive health plan premium?
Report single service insurance plans only.
Do not include single services covered under a
comprehensive health plan.
Long-term care insurance helps to cover the cost of
institutional and home care required by the chronically ill or
disabled.
Mark (X) all that apply.
What was the total amount paid for optional
coverage for all ACTIVE employees at THIS
GOVERNMENT UNIT in 2006?
For 2006, did your government unit impose a
waiting period before new employees could be
covered by health insurance?
For 2006, what was the TYPICAL waiting period?

}

195

Dental
Vision
Prescription drugs
Long-term care

562

No optional coverage – SKIP to Question 2a

192
193
194

Continue with Question 1b

196

$

,

,

,

. 0 0

Optional coverage cost
197

1
2

198

Mark (X) only one.

1
2
5
3
4

Yes – Continue with Question 2b
No – SKIP to Section E
Less than 2 weeks
2 weeks to less than 1 month
Until the first day of the next month
1–3 months
More than 3 months

Section E – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility, and
enrollment figures.
Include part-time, temporary, and seasonal employees.
Exclude leased or contract workers and retirees.

1a.
b.
2a.

How many ACTIVE employees were ELIGIBLE for at
least one health plan through your government unit
in 2006?

201

How many of those ACTIVE employees were
ENROLLED in ANY health plan through your
government unit?

202

Did your government unit have any part-time
employees in 2006?

563

Eligible employees

Enrolled employees

2

If your government unit did not offer health
insurance in 2006, then SKIP to Page 4, Section F.

b.
c.
3.

1

3

How many of those part-time employees were
ELIGIBLE for at least one health plan through your
government unit?

204

How many of those part-time employees were
ENROLLED in ANY health plan through your
government unit?

205

Did your government unit offer health insurance to
its temporary or seasonal employees in 2006?
Mark (X) only one.

564

Eligible part-time employees

Enrolled part-time employees
1
2
4
3

4.

If your government unit offered health insurance,
how many hours per week must an employee work
to be eligible for health insurance?

FORM MEPS-11(R) (4-26-2007)

Yes – Continue with Question 2b
⎫
No
⎬ SKIP to Question 3
Don’t know ⎭

Yes
No
No temporary or seasonal employees
Don’t know

626

Hours worked per week to be eligible
Page 3

Section F – FRINGE BENEFITS CHARACTERISTICS

1.

Which of the following fringe benefits did your
government unit offer its employees in 2006?
050
051
052
053
054

2.

Paid vacation . . . . . . .
Paid sick leave . . . . . .
Life insurance . . . . . . .
Disability insurance . . . .
Retirement/pension plans

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

.
.
.
.
.

627

Employee contributions to health
insurance made on a pre-tax basis

056

Flexible SPENDING account (FSA)
for healthcare
Flexible Benefits Plans
Full cafeteria plans that offer employees
a set of benefits from which to choose

These plans are also known as Section 125 Cafeteria Plans.
057

No
(2)

Don’t
know
(3)

Yes
(1)

No
(2)

Don’t
know
(3)

.
.
.
.
.

Did your government unit offer any of these
tax-advantaged benefits to its employees in 2006?
See the Definition Sheet included with this package for an
explanation of these benefits.

Yes
(1)

Section G – EMPLOYEE CHARACTERISTICS
Provide information for a TYPICAL pay period in
2006.
Estimates are acceptable.
The following workforce characteristics are used to group
similar government units together for analytical purposes.
If none, enter "0".

016

%

1.

Approximately what percentage of the employees
at this government unit were women?

2.

Approximately what percentage of the employees
at this government unit were 50 years old or older?

017

Approximately what percentage of the employees
at this government unit were union members?

018

3.
4.

For the employees at this government unit in
2006, approximately what percentage earned –

022

Less than $10.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $21,840 a year or less

023

Between $10.50 and $23.50 per hour? . . . . . . . . . .
Approximately $21,840 to $48,800 a year

024

%
%

%
%
%

More than $23.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $48,880 a year or more

Women employees

Employees 50 years old or older

Union members

Earned less than $10.50 per hour
Earned between $10.50 and $23.50 per hour
Earned more than $23.50 per hour

Section H – PERSON COMPLETING THIS QUESTIONNAIRE
212

213

Name (Please print)

Title

Signature

214

M
215

Telephone number

(
Page 4

)

220

Extension

216

(

FAX number

217

Date (Month/Day/Year)
M

D

D

Y

Y

Y

Y

E-Mail address

)

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

FORM MEPS-11(R) (4-26-2007)

OMB No. 0935-0110: Approval Expires

2006 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY
Company Questionnaire

(Please correct any errors in name, address, and ZIP Code.
Enter number and street if not shown.)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

RETURN TO

U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001
Fax to 1-800-447-4613

PLEASE RETURN ENTIRE PACKAGE WITHIN

PLEASE DO NOT REMOVE THIS COVER SHEET
FORM

MEPS-15

(4-24-2007)

OR

INSTRUCTIONS
1. Please report for the company identified on the cover sheet, unless
otherwise specified.
A COMPANY, for the purposes of this study, is a business with its
own management and legal structure. A company represents the
entire organization, including the headquarters and all divisions,
subsidiaries, and branches within the organizational family.
2. Please report data for the year 2006.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the Definition Sheet
included with this package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a completed copy of this form for your records.
7. If you have any questions or need assistance in completing
the questionnaire, please call 1-888-206-8023 or visit
http://www.census.gov/econhelp/meps/cmu/index.html

Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, per company, to complete the basic questionnaire. Companies with more
than one health plan will take an additional 10 minutes per plan, on average, up to the maximum of three plans to be reported.
In addition, we estimate that it will take 15 minutes to review the instructions and locate the requested information. You may
send any comments regarding this burden estimate or any other aspect of the collection of information, including suggestions
for reducing burden, to the following address: Director, Center for Financing, Access and Cost Trends, Paperwork Reduction
Project 0935-0110, Agency for Healthcare Research and Quality, Room 5030, 540 Gaither Road, Rockville, MD 20850. Please
do not mail questionnaires to this address as it will delay data processing.

Page 2

FORM MEPS-15 (4-24-2007)

Section A – NUMBER OF PLANS

1a.

Are you reporting for your entire company?

535

1
2

b.

If you are reporting for a portion of your total
company, approximately what percentage of
the company’s total 2006 employment are you
reporting?

Yes – SKIP to Question 2a
No – Continue with Question 1b

528

%
529

Company employment

Briefly explain

Respond for ACTIVE employees only.

2a.

Did your company make available or contribute
to the cost of any health insurance plans for its
ACTIVE employees in 2006?

001

1
2

Yes – Continue with Question 2b
No – SKIP to Page 4, Section B

For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.

b.

On average, how many different health
insurance choices did your company make
available or contribute to for its ACTIVE
employees at a TYPICAL location during the
2006 plan year?

003

Health insurance choices at a
typical location

Report for a single establishment within your company
which you think offered a "TYPICAL" array of health
insurance plans.
Do not count single service plans (optional plans) such as
dental or vision.
Plans offered by the same insurance company which
offer:
• Single, employee-plus-one, and family coverage
providing the same level of benefits count as one
plan.
• High and standard options count as two plans.
• An HMO and a conventional plan count as two
plans.

FORM MEPS-15 (4-24-2007)

Page 3

Section B – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include officers, owners, part-time, temporary and
seasonal employees.
Exclude former employees, leased or contract workers and
retirees.

1a.

What was the total number of employees your
company had at ALL locations for a TYPICAL
pay period in 2006?

034

Employees at all locations
If your company did not offer health
insurance in 2006, SKIP to Question 2a

b.

c.

2a.

How many of these employees were ELIGIBLE
for at least one health plan through your
company?

201

How many of these employees were ENROLLED
in ANY health plan through your company?

202

For the same TYPICAL pay period in 2006,
how many of the employees reported in B1a
worked part-time?

203

Eligible employees

Enrolled employees

Part-time employees
If your company did not offer health
insurance in 2006, SKIP to Page 5, Question 6a

b.

c.

3.

How many of these part-time employees were
ELIGIBLE for at least one health plan through
your company?

204

How many of these part-time employees were
ENROLLED in ANY health plan through your
company?

205

Did your company offer health insurance to
its temporary or seasonal employees in
2006?

564

Eligible part-time employees

Enrolled part-time employees

2
4

Mark (X) only one.

4.

Page 4

If your organization offered health insurance,
how many hours per week must an employee
work to be eligible for health insurance?

1

3

Yes
No
No temporary or seasonal employees
Don’t know

626

Hours worked per week to be eligible

FORM MEPS-15 (4-24-2007)

Section B – EMPLOYMENT CHARACTERISTICS – Continued

5.

Of the active employees enrolled in a health
insurance plan your company offered in 2006,
what percentage were ENROLLED in each of the
following types of plans?

Active enrollment by type –

Exclusive providers – Enrollees must go to providers
associated with the plan for all non-emergency care in
order for the costs to be covered.

518

Any providers – Enrollees may go to providers of their
choice with no cost incentives to use a particular group of
providers.

519

Mixture of preferred and any providers –
Enrollees may go to any provider, but there is a cost
incentive to use a particular group of providers.

% Exclusive providers (Examples:

Most HMO, IPA, and EPO-type plans)

% Any providers (Examples: Most
fee-for-service plans)

Mixture of preferred and any

520

% providers (Examples: Most PPO
and POS-type plans)

Provide information for a TYPICAL pay period in 2006.
Estimates are acceptable.
The following workforce characteristics are used to group
similar companies together for analytical purposes.
If none, enter "0".

6a.
b.

c.

d.

Approximately what percentage of the total
employees at your company were women?

016

Approximately what percentage of the total
employees at your company were 50 years old
or older?

017

Approximately what percentage of the total
employees at your company were union
members?

018

%

%

%

Women employees

Employees 50 years old or older

Union members

For the employees at your company in 2006,
approximately what percentage earned –
022

Less than $10.50 per hour? . . . . . . . . . . . . . . . .
Approximately $21,840 a year or less
Between $10.50 and $23.50 per hour? . . . . . . . .
Approximately $21,840 to $48,880 a year
More than $23.50 per hour? . . . . . . . . . . . . . . . .
Approximately $48,880 a year or more

FORM MEPS-15 (4-24-2007)

023

024

%
%
%

Earned less than $10.50 per hour
Earned between $10.50 and $23.50
per hour
Earned more than $23.50 per hour

Page 5

Section C – BUSINESS CHARACTERISTICS

1a.

Which of the following fringe benefits did your
company offer its employees in 2006?
Mark (X) all that apply.

Paid vacation . . . . . . . .
Paid sick leave . . . . . . .
Life insurance . . . . . . . .
Disability insurance . . . .
Retirement/pension plans

050
051
052
053
054

b.

.
.
.
.
.

Approximately how many years has your parent
company been in business?

Employee contributions to health
insurance made on a pre-tax basis

056

Flexible SPENDING Accounts (FSA)
for healthcare

057

Flexible Benefits Plans
Full cafeteria plans that offer
employees a set of benefits from
which to choose

588

Mark (X) only one.
How many establishments does your company
operate nationally?

No

Don’t know

(1)

(2)

(3)

Yes

No

Don’t know

(1)

(2)

(3)

.
.
.
.
.

627

These plans are also known as Section 125 Cafeteria Plans.

3.

.
.
.
.
.

Did your company offer any of the following
tax-advantaged benefits to its employees in 2006?
See the Definition Sheet included with this package for an
explanation of these benefits.

2.

.
.
.
.
.

Yes

Less than 1 year
1–2 years

4

2

5

5–9 years
10–19 years

3

3–4 years

6

20 years or more

1

530

Establishments
If your company did not offer health insurance in
2006, SKIP to Page 9, Section F

Page 6

FORM MEPS-15 (4-24-2007)

Section D – RETIREE HEALTH COVERAGE CHARACTERISTICS
Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws. See the Definition Sheet
included with this package for an explanation of these terms.
If this is a self-insured plan, report the premium equivalent.

1.

2.

Did your company provide health insurance
coverage to any person who retired ON OR
BEFORE December 31, 2006, or to any of their
survivors?

551

In 2006, what was the total number of retirees
enrolled in health insurance through your
company?

513

Yes – Continue with Question 2
No
SKIP to Page 9, Section E
Don’t know

1

}

2
3

Total retirees enrolled

UNDER 65 YEARS OF AGE
Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws.

3a.

Were any of the enrolled retirees, reported in
Question 2, under 65 years of age?

628

b.

What was the TOTAL number of retirees under 65
years of age enrolled in health insurance through
your company at all of its locations in 2006?

572

c.

What percentage of these retirees were
ENROLLED in SINGLE coverage?

573

d.

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE coverage?

574

e.

For this same plan, what was the TOTAL monthly
premium for this typical retiree with SINGLE
coverage?

575

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
For retirees, if premium varied by family size, report for a family
of two.

576

For this same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?

577

f.

g.

FORM MEPS-15 (4-24-2007)

Yes – Continue with Question 3b
No – SKIP to Page 8, Question 4a

1
2

Total retirees under 65 enrolled
in health insurance

under 65 enrolled
% Retirees
in single coverage

$

,

. 0 0

Employer
contribution for
single premium

$

,

. 0 0

Total single
premium

$

,

. 0 0

Employer
contribution for
family premium

$

,

. 0 0

Total family
premium

Page 7

Section D – RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
AGE 65 YEARS OR OVER
Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws.

4a.

Were any of the enrolled retirees, reported in
Question 2, 65 years of age or over?

629

b.

What was the TOTAL number of retirees 65 years
of age or over enrolled in health insurance through
your company in 2006?

578

c.

What percentage of these retirees were
ENROLLED in SINGLE coverage?

579

d.

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE coverage?

580

e.

For this same plan, what was the TOTAL monthly
premium for this typical retiree with
SINGLE coverage?

581

For a typical plan in 2006, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
For retirees, if premium varied by family size, report for a family
of two.

582

For this same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?

583

f.

g.

Yes – Continue with Question 4b
No – SKIP to Question 5a

1
2

Total retirees 65 or over enrolled
in health insurance

Retirees 65 or over enrolled in single
% coverage

$

,

. 0 0

Employer
contribution for
single premium

$

,

. 0 0

Total single
premium

$

,

. 0 0

Employer
contribution for
family premium

$

,

. 0 0

Total family
premium

NEW RETIREES
For questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your organization in 2006.

Exclude any retirees that have coverage through COBRA or
State Continuation-of-Benefits laws.

5a.

Did your organization offer health insurance to
any NEW RETIREES?

630

1
2
3

b.

Were NEW RETIREES under 65 years of age eligible
for health insurance?

631

1
2
3

c.

Were NEW RETIREES 65 years of age or over eligible
for health insurance?

632

1
2
3

Page 8

Yes – Continue with Question 5b
No
SKIP to Page 9, Section E
Don’t know

}

Yes
No
Don’t know
Yes
No
Don’t know

FORM MEPS-15 (4-24-2007)

Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS

1a.

Which of the listed optional coverage services,
if any, did your company offer to its ACTIVE
employees in 2006 at a premium SEPARATE
from the comprehensive health plan premium?

192

Report single service insurance plans only.

195

Dental
Vision
Prescription drugs
Long-term care

562

No optional coverage – SKIP to Question 2a

Do not include single services covered under a
comprehensive health plan.

193
194

}

Continue with Question 1b

Long-term care insurance helps cover the cost of
institutional and home care required by the chronically ill
or disabled.
Mark (X) all that apply.

b.

What was the total amount paid for optional
coverage for all ACTIVE employees at your
company in 2006?

196

,

$

,

,

. 0 0

Optional coverage cost

Include both employer and employee contributions.

2a.

b.

For 2006, did your company impose a waiting
period before new employees could be covered
by health insurance?

197

For 2006, what was the TYPICAL waiting
period?

198

Mark (X) only one.

2

Yes – Continue with Question 2b
No – SKIP to Section F

1

Less than 2 weeks

2

2 weeks to less than 1 month

5

Until the first day of the next month

3

1–3 months

4

More than 3 months

1

Section F – PERSON COMPLETING THIS QUESTIONNAIRE

*** PLEASE NOTE ***
If your company offered health insurance, please complete Section F and
an attached MEPS-15(S), Plan Information Questionnaire, for each plan
offered up to three.
If your company DID NOT offer health insurance, please complete Section
F and SKIP to the attached MEPS-15(E), Establishment Worksheet.

212

213

Name (Please print)

670

Signature

Title

Website address

214

M

Date (Month/Day/Year)
M

D

D

Y

Y

Y

Y

http: //
215

Telephone number

(

)

FORM MEPS-15 (4-24-2007)

220

Extension

216

FAX number

(

217

E-Mail address

)

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

Page 9

500

Remarks

Page 10

FORM MEPS-15 (4-24-2007)

OMB No. 0935-0110: Approval Expires

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

•
Start
here

Medical Expenditure Panel Survey – Insurance Component

HEALTH INSURANCE COST STUDY
Location Worksheet

A FEW IMPORTANT INSTRUCTIONS
• In this section, please report for the small sample of locations chosen to represent your company.
• In Column (c), mark "Yes" if the location listed in Column (b) is included in the corporate figures reported on the
MEPS-15. Mark "No" if the location is not included in the corporate figures reported on the MEPS-15.
• In Column (d), enter the number of employees at the location listed in Column (b) for a typical pay period in
2006. Estimates are acceptable.
• In Columns (e), (f), and (g), please check the types of hospital and/or physician insurance plans which your
company offered at the location specified in Column (b). See the MEPS-20D, Definition Sheet, included in this
package for detailed explanations of the different types of plans.

CENSUS USE ONLY
Location
identification number
(a)

Name of location

Have you
answered
for this
location on
the
MEPS-15?

(b)

(c)
524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

FORM

MEPS-15(E) (4-4-2007)

Number
of
employee(s)

1

YES

2

NO

(d)

Types of Insurance
Offered
Mark (X) all that apply
HMO/
EPO

Conventional
Indemnity

(e)

(f)

PPO/
POS
(g)

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

CENSUS USE ONLY
Location
identification number
(a)

Name of location

Have you
answered
for this
location on
the
MEPS-15?

(b)

(c)
524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

1

YES

2

NO

524

FORM MEPS-15(E) (4-4-2007)

Number
of
employee(s)

1

YES

2

NO

(d)

Types of Insurance
Offered
Mark (X) all that apply
HMO/
EPO
(e)

Conventional
Indemnity
(f)

PPO/
POS
(g)

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523

200

521

522

523