Form #3 Form #3 Plan Questionnaire

2008 and 2009 Medical Expenditure Panel Survey - Insurance Componenet (MEPS-IC)

ATTACHMENT R Plan Questionnaires

2008 and 2009 Medical Expenditure Panel Survey - Insurance Component Plan Questionnaire

OMB: 0935-0110

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0935-0110 can be found here:

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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

2006 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2006 AT
THE LOCATION LISTED ABOVE.
You may use photocopies of this MEPS-10(S) form if sufficient copies were not included in this reporting
package.

GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
If a plan name is preprinted in the question 1 answer box on
the right, answer for the plan specified. Otherwise, complete
this Plan Information Questionnaire for the plan with the
largest (or next largest) enrollment of active employees.

For 2006, what was the name of the health
insurance plan with the largest (or next largest)
enrollment of ACTIVE employees?
Examples:

100

Name of plan
012

• Blue Cross Blue Shield, High Option
• Company Plan A
• Aetna HMO

Which type of health care provider was available
through this plan?

103

Exclusive providers – Enrollees must go to providers
associated with the plan for all non-emergency care in order
for the costs to be covered.
Any providers – Enrollees may go to providers of their
choice with no cost incentives 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 providers
(Examples: Most PPO and POS-type plans)

Yes
No
Don’t know

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.

Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order to
be referred to a specialist?
For plans with multiple options, answer for the "in-network"
option.
Was this plan offered through a union or a
trade association?

104

2
3

113

1
2
3

Union
Trade association
Neither
Continue with Page 2, Question 5

FORM

MEPS-10(S) (4-27-2007)

GENERAL PLAN INFORMATION – Continued

Was this plan purchased from an insurance
underwriter or was it self-insured?

105

1
2

Purchased from an insurance underwriter –
(Fully-insured) Coverage is purchased from an insurance
company or other underwriter who assumes the risk for
enrollees’ medical expenses.

Purchased – SKIP to Question 7a
Self-insured – Continue with Question 6a
Don’t know – SKIP to Question 7a

Self-insured – Your organization assumes the risk for the
enrollees’ medical expenses and may charge a premium to
employees. This plan may be administered by a third party and
may employ supplemental stop-loss insurance to limit
unanticipated losses.

SELF-INSURED PLAN INFORMATION
Complete questions 6a–b if this plan was self-insured.

6a.

Did your organization employ a third party
administrator (TPA) for this self-insured plan?

Did your organization purchase stop-loss coverage
for this plan?

713

1
2

107

1
2

Yes – used a third party administrator
No – self-administered the plan

Yes
No

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.

7a.

How many ACTIVE employees at this location were
ENROLLED in this plan during a typical pay period in
2006?

125

Active employees enrolled in
plan

Include full-time, part-time, temporary and seasonal employees.
Exclude former employees, leased or contract workers and
retirees.

How many of these ACTIVE employees were
ENROLLED in SINGLE coverage during a typical pay
period in 2006?

129

Active employees enrolled in
single coverage

EMPLOYEE-PLUS-ONE coverage is health insurance coverage
for an employee-plus-spouse or an employee-plus-child(ren) AT
A LOWER PREMIUM than family coverage.

If your organization offered EMPLOYEE-PLUS-ONE
coverage, how many ACTIVE employees were
ENROLLED during a typical pay period in 2006?

571

Active employees enrolled in
employee-plus-one coverage

Include enrollment for both employee-plus-spouse and
employee-plus-child(ren) coverage.

How many ACTIVE employees were ENROLLED in
FAMILY (not single or employee-plus-one) coverage
during a typical pay period in 2006?

705

Active employees enrolled in
family coverage

COBRA ENROLLMENT

How many FORMER employees were
ENROLLED in this plan, excluding retirees,
through PHSA (COBRA) or other State
Continuation-Of-Benefits laws during a typical
pay period in 2006?

126

Former employees enrolled in plan,
excluding retirees

Continue with Page 3, Question 9a
Page 2

FORM MEPS-10(S) (4-27-2007)

PLAN PREMIUMS
Report for TYPICAL situations and enrollees. If premium varied, report for a TYPICAL employee.
If this was a self-insured plan, report the premium equivalent.
Report employer/employee contributions and total premium for the same period during 2006.
Include any subsidy from an outside third party in the employee contribution for premiums.
If there is an HSA or HRA associated with this plan, include any employer contributions to an HSA or HRA
account in the employer premium or total premium below.

SINGLE COVERAGE

9a.
b.

552

Was SINGLE coverage offered under this plan?
For this plan, how much did the EMPLOYER
contribute toward the plan premium of one typical
employee with SINGLE coverage?

. 0 0

Employer
contribution for
single premium

. 0 0

Employee
contribution for
single premium

. 0 0

Total single
premium

131

How much did this typical EMPLOYEE with SINGLE
coverage contribute toward his/her own premium?

132

What was the TOTAL premium for this typical
employee with SINGLE coverage?

130

The amounts reported in questions 9b–d are based
on which one of the following time periods?

Yes – Continue with Question 9b
No – SKIP to Question 10a

133

Weekly
Every 2 weeks

1
2

Mark (X) only one.

Monthly
Quarterly
Yearly

3
5
4

EMPLOYEE-PLUS-ONE COVERAGE
EMPLOYEE-PLUS-ONE coverage is health insurance
coverage for an employee-plus-spouse or an
employee-plus-child(ren) AT A LOWER PREMIUM LEVEL
than family coverage.
If employee-plus-one premiums were different for
employee-plus-child(ren) and employee-plus-spouse coverages,
report for employee-plus-one child. If premiums varied for other
reasons, report for a TYPICAL employee.

10a.

Was EMPLOYEE-PLUS-ONE coverage offered
under this plan?

570

For this plan, how much did the EMPLOYER
contribute toward the plan premium of one typical
employee with EMPLOYEE-PLUS-ONE coverage?

636

How much did this typical EMPLOYEE with
EMPLOYEE-PLUS-ONE coverage contribute toward
his/her own premium?

637

What was the TOTAL premium for this typical
employee with EMPLOYEE-PLUS-ONE coverage?

635

The amounts reported in questions 10b–d are based
on which one of the following time periods?

638

Mark (X) only one.

. 0 0

Employer
contribution for
employee-plus-one
premium

. 0 0

Employee
contribution for
employee-plus-one
premium

. 0 0

Total
employee-plus-one
premium

1
2
3
5
4

FORM MEPS-10(S) (4-27-2007)

Yes – Continue with Question 10b
No – SKIP to Page 4, Question 11a

Weekly
Every 2 weeks
Monthly
Quarterly
Yearly

Continue with Page 4, Question 11a
Page 3

PLAN PREMIUMS – Continued
FAMILY COVERAGE
If premium varied by family size, report for a family of four.

11a.

137

Yes – Continue with Question 11b
No – SKIP to Question 12a

1
2

Was FAMILY coverage offered under this plan?

For this plan, how much did the EMPLOYER
contribute toward the plan premium of one
typical employee with FAMILY coverage?

135

How much did this typical EMPLOYEE with FAMILY
coverage contribute toward his/her own premium?

136

What was the TOTAL premium for this typical
employee with FAMILY coverage?

134

The amounts reported in questions 11b–d are based
on which one of the following time periods?

553

. 0 0

Employer
contribution for
family premium

. 0 0

Employee
contribution for
family premium

. 0 0

Total family
premium

Weekly
Every 2 weeks

1
2

Mark (X) only one.

Monthly
Quarterly
Yearly

3
5
4

GENERAL PREMIUM INFORMATION

12a.

Did the PREMIUMS charged by the insurance
company or carrier vary by any of these
characteristics?

139
141

Mark (X) all that apply.

Age
Gender
Wage or salary levels
Other
OR

138

142

Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?

640

Premiums did not vary

641

Hours worked
Union status
Wage or salary level
Occupation
Length of employment
Other
OR
Employee contribution did not vary

642
643

Mark (X) all that apply.

644
706
645

646

INDIVIDUAL DEDUCTIBLES

13a.

Did this plan have a deductible?
Deductible – Predetermined amount which must be paid by an
individual before the plan will reimburse for covered services.

151

Yes – Continue with Question 13b
No – SKIP to Page 5, Question 16a

1
2

Many HMOs do not have a deductible.

What was the annual deductible an individual
paid?

146

Report "IN-NETWORK" deductibles (if applicable).
If separate deductibles apply, enter physician care and
hospital care amounts in appropriate boxes.
If deductible is per overnight hospital stay, it is not
an annual deductible and should be reported
under 16b on Page 5.
DO NOT report COPAYMENTS or individual or
family out-of-pocket maximums here.
Page 4

. 0 0

Individual annual
deductible

OR
Separate deductibles for:
147

. 0 0

Physician care

. 0 0

Hospital care

148

FORM MEPS-10(S) (4-27-2007)

FAMILY DEDUCTIBLES

14a.

Did this plan require that a specific number of
family members meet their individual deductibles
before the family deductible was met?

224

1
2
3

How many family members were required to
meet their individual deductibles before the
family deductible was met?

Yes – Continue with Question 14b
No – SKIP to Question 14c
Family coverage not offered – SKIP to Question 15a

150

Number of family members

Report for a family of four.

What was the total annual deductible a family
paid?

149

. 0 0

Total annual family
deductible

Report for a family of four.

HEALTH SAVINGS ACCOUNT (HSA)

15a.

If the deductibles you reported in questions 13 and
14 were $1,050 or higher for single coverage and
$2,100 or higher for family coverage, did you
contribute to a Health Savings Account (HSA) for
the plan enrollees in 2006?

714

How much did the employer contribute monthly
to an enrollee’s account for single coverage?

716

How much did the employer contribute monthly
to an enrollee’s account for family coverage?

717

1
2
4

Yes, contributed to an HSA – Continue with Question 15b
No, did not contribute to an HSA – SKIP to Question 16a
Don’t know – SKIP to Question 16a

. 0 0

Monthly contribution
for single HSA

. 0 0

Monthly contribution
for family HSA

Report monthly contributions.
HSAs are NOT Flexible Spending Accounts (FSAs)
or Health Reimbursement Arrangements (HRAs).
See definition sheet for more information.

PAYMENTS

16a.

Was hospital care covered under this plan?

155

Yes – Continue with Question 16b
No – SKIP to Question 16c

1
2

How much and/or what percentage of the total bill
did an enrollee pay out-of-pocket for an inpatient
hospital admission after any annual deductible was
met?
Out-of-pocket expense – Those costs paid directly by
the enrollee.
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).
Report for an admission at an "in-network"/participating
hospital (if applicable).
Do not include any physician charges incurred during the
hospital admission.

152

Was physician care covered under this plan?

218

$
154

1
2

How much and/or what percentage of the total bill
did an enrollee pay out-of-pocket for an office visit
after any annual deductible was met?
Out-of-pocket expense – Those costs paid directly by
the enrollee.
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for an "in-network"/participating general practitioner
during normal office hours.

FORM MEPS-10(S) (4-27-2007)

. 0 0

Copayment paid by enrollee
for hospital admission

Per day
Per stay
AND/OR

153

% Coinsurance
paid by enrollee

1
2

Yes – Continue with Question 16d
No – SKIP to Page 6, Question 17

156

. 0 0

Copayment paid by enrollee
for office visit

AND/OR
157

% Coinsurance
paid by enrollee
Continue with Page 6, Question 17
Page 5

PAYMENTS – Continued

17.

Were prescription drugs covered under this
health plan?

673

Yes
No
Don’t know

1
2
3

18.

How many different pricing categories or tiers of
prescription drug coverage were there for this
plan?

How much and/or what percentage did an
enrollee pay out-of-pocket for the lowest
tier of prescription drug coverage?

SKIP to Question 20a

712

Number of tiers
715

19.

}

Don’t know
Lowest cost to enrollee

655

. 0 0

Report for the least expensive pharmacy available to
the enrollee under the plan, excluding any mail-order
programs.

Copayment
And/Or
677

%
Coinsurance

20a.

Include all copayments, coinsurance and deductibles.
What was the MAXIMUM ANNUAL out-of-pocket
expense for an individual?
Out-of-pocket expense – Those costs paid directly by
the enrollee.

161

. 0 0

OR
No individual maximum

163

This is often referred to as a catastrophic limit.

What was the MAXIMUM ANNUAL out-of-pocket
expense for a family of four?

162

What was the MAXIMUM amount this plan would
have paid for an enrollee in ONE YEAR?

. 0 0

OR
No family maximum

222

21.

160

. 0 0

OR
No annual maximum

221

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

22.

An employer can offer a Health Reimbursement
Arrangement (HRA) by setting up an account to
reimburse employees for medical expenses not
covered by health insurance. Did your
organization offer a Health Reimbursement
Arrangement (HRA) associated with this plan
in 2006?

710

1
2
3

Yes
No
Don’t know

HRAs are NOT Flexible Spending Accounts (FSAs)
or Health Savings Accounts (HSAs).
See definition sheet for more information.

Page 6

Continue with Page 7, Question 23

FORM MEPS-10(S) (4-27-2007)

PLAN CHARACTERISTICS

23.
24.
25.

Could this plan have refused to cover persons
with pre-existing medical or health conditions?

183

Did this plan have a policy requiring a waiting
period before covering pre-existing conditions?

185

1
2

Yes
No
Yes
No

Which of the services listed were covered by
this plan?

Yes
(1)
173

Chiropractic care . . . . . . . . . . . . . . . .

587

Routine vision care . . . . . . . . . . . . . . .

176

Routine dental care . . . . . . . . . . . . . . .

No
(2)

Don’t
know
(3)

*** PLEASE NOTE ***
If your organization offered only one health insurance plan,
please end the form.
If your organization offered MORE THAN ONE health insurance
plan, please complete a Plan Information Questionnaire for each
plan that was offered, up to four plans.

FORM MEPS-10(S) (4-27-2007)

Page 7

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

2006 Medical Expenditure Panel Survey

Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
UNION

Please correct errors in name, address, and ZIP Code.
ENTER number and street if not shown.

PLAN INFORMATION
FOR CENSUS USE ONLY
100

DNK

Name of union plan from the establishment interview

1a. The name of the (first/next)health insurance plan provided under the collective
bargaining agreement at the location I mentioned earlier was reported as (fill in plan
name). Is this correct?
Yes – TRANSCRIBE PLAN NAME INTO 1b AND GO TO QUESTION 2
No – CONTINUE WITH 1b.

DNK

1b. For 2006, what was the name of the health insurance plan with the (largest/next largest)
enrollment of actively-employed members which your union offered at that location?
012

Name of plan
The following questions are about (fill in plan name from above).
2.

Was this plan PURCHASED from an insurance underwriter or was it SELF-INSURED?
105

2
3

Purchased from an insurance underwriter (fully insured) –
SKIP TO QUESTION 5 ON PAGE 2
Self insured – CONTINUE WITH QUESTION 3 ON PAGE 2
Don’t know – SKIP TO QUESTION 5 ON PAGE 2

READ IF NECESSARY: Coverage is underwritten by an insurer if your union paid a
fixed amount to the insurer (usually monthly) and the insurer paid the enrollee’s
claims. The plan is self-insured if your union paid for the enrollee’s claims — either
directly or through a Third Party Administrator (TPA).
FORM

MEPS-10M(U) (4-20-2007)

PLAN INFORMATION – Continued
3.

Did you employ a Third Party Administrator (TPA) for this self-insured plan?
713

1
2

Did the union purchase stop-loss coverage?
107

1
2

Any providers the enrollee chooses with no cost incentives to use a
particular group of providers; OR (Most fee-for-service plans)
A mixture of preferred providers and any providers, where the enrollee
may go to any provider, but there is a cost incentive to use a particular
group of providers. (Most PPO, POS type plans)

Did this plan require that the enrollee see a gatekeeper or primary-care physician in
order to be referred to a specialist?
104

1
2
3

Yes
No

Which type of health care providers were available through (fill plan name)?
Were the providers –
DO NOT READ TERMS IN

PARENTHESES
103
1
Exclusive providers the enrollee must use in non-emergency
situations, (HMO, IPA, EPO type plans)
2

Yes
No

Yes
No
Don’t know

Was this plan considered a composite plan?
READ IF NECESSARY: A composite plan is a plan where the premium and member
contribution rates do not vary between single and family coverage.
656

1
2
3

Page 2

Yes – SKIP TO 10b ON PAGE 4
No
Don’t know

FORM MEPS-10M(U) (4-20-2007)

PLAN INFORMATION – Continued
8a. Was single coverage offered under this plan?
552

1
2

Yes
No – SKIP TO 9a

8b. For this plan, how much did one typical, actively-employed member with single
coverage contribute toward his or her own premium?
132

.00 Member contribution – single premium

623

Weekly

Every two weeks

Monthly

Quarterly

Yearly

Hourly

8c. What was the (If self-insured ‘premium equivalent’, else, ‘total premium’) for this
typical, actively-employed member with single coverage, including both the
employer and member contributions?
130

.00 Total single premium

8d. On which of the following time periods are these amounts reported:
weekly, every 2 weeks, monthly, quarterly, yearly, or hourly?

133

Weekly

Every two weeks

Monthly

Quarterly

Yearly

Hourly

9a. Was member-plus-one coverage offered under this plan?
READ IF NECESSARY: Member-plus-one coverage is health insurance coverage for a
member-plus-spouse or member-plus-child(ren) at a lower premium than family
coverage.
570

Yes

No – SKIP TO 10a ON PAGE 4

9b. For this plan, how much did one typical, actively-employed member with
member-plus-one coverage contribute toward his or her own premium?
Member contribution –
.00 member-plus-one premium

637

639

Weekly

Every two weeks

Monthly

Quarterly

Yearly

Hourly

9c. What was the (If self-insured ‘premium equivalent’, else, ‘total premium’) for this
typical, actively-employed member with member-plus-one coverage, including
both the employer and member contributions?
635

FORM MEPS-10M(U) (4-20-2007)

.00 Total member-plus-one premium

Page 3

PLAN INFORMATION – Continued
9d. On which of the following time periods are these amounts reported:
weekly, every 2 weeks, monthly, quarterly, yearly, or hourly?

638

Weekly

Every two weeks

Monthly

Quarterly

Yearly

Hourly

10a. Was family coverage offered under this plan?
137

Yes
No – SKIP TO 11a

1
2

10b. For this plan, how much did one typical, actively-employed member with
(family/composite) coverage contribute toward his or her own premium?
READ IF NECESSARY: If premium varied by family size, report for a family of four.
136

.00 Member contribution – Family/composite
premium

624

Weekly

Every two weeks

Monthly

Quarterly

Yearly

Hourly

10c. What was the (If self-insured, ‘premium equivalent’, else, ‘total premium’) for this
typical, actively-employed member with (family/composite) coverage, including
both the employer and member contributions?
134

.00 Total family/composite premium

10d. On which of the following time periods are these amounts
reported: weekly, every 2 weeks, monthly, quarterly, yearly, or hourly?

553

Weekly

Every two weeks

Monthly

Quarterly

Yearly

Hourly

11a. Did the premiums charged by the insurance company or carrier vary by
any of the following characteristics:
Age?
138
Gender?
139
Wage or salary levels?
141
Other?
142
OR
640

Page 4

Did the premiums not vary?

FORM MEPS-10M(U) (4-20-2007)

PLAN INFORMATION – Continued

11b. Did the amount an actively-employed member contributed toward his/her own coverage
vary by any of the following member characteristics:
641
643
644
706
645

Hours worked?
Wage or salary level?
Occupation?
Length of Employment?
Any other member characteristics?
OR

646

Did the member contribution not vary?

12a. Approximately how many of your members were employed at the establishment
I mentioned earlier, during a typical pay period in 2006?
Employed members

647

12b. What percentage of these union members were enrolled in this plan during 2006?
READ IF NECESSARY: What percentage of ALL union members were enrolled in this
plan during 2006?
% of members enrolled

648

13a. For this plan, approximately what percentage of these enrollees had single coverage?
542

% of enrollees in single coverage
OR
129

Number of enrollees in single coverage

13b. For this plan, approximately what percentage of the enrollees had
member-plus-one coverage?
621

% of enrollees in member-plus-one coverage
OR
571

Number of enrollees in member-plus-one coverage
FORM MEPS-10M(U) (4-20-2007)

Page 5

PLAN INFORMATION – Continued
14a. Did this plan have a deductible?
151
1
Yes
No – SKIP TO 17a ON PAGE 7
2
14b. What was the annual deductible an individual paid?
146

.00 Individual annual deductible

OR
Separate deductibles for physician care and hospital care:
147

.00 Physician care

.00 Hospital care

148

15a. Did this plan require that a specific number of family members meet their
individual deductibles before the (family/composite) deductible was met?
224
1
Yes
2
No – SKIP TO 15c
15b. How many family members were required to meet their individual deductibles before
the (family/composite) deductible was met?
150

Number of family members
15c. What was the total annual deductible a family paid?
149

.00 Total annual family deductible

16a. If the deductibles for this plan were $1,050 or higher for single coverage, and/or $2,100
or higher for family coverage, did the union contribute to a Health Savings Account
(HSA) for the plan enrollees in 2006?
READ IF NECESSARY: HSAs are NOT Flexible Spending Accounts (FSAs) or Health
Reimbursement Arrangements (HRAs).
714
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA – SKIP TO 17a ON PAGE 7
4
Don’t know – SKIP TO 17a ON PAGE 7
16b. What was the union monthly contribution to a member’s account for single coverage?
716

.00 Monthly contribution for single HSA

16c. What was the union monthly contribution to a member’s account for family coverage?
717

$
Page 6

.00 Monthly contribution for family HSA
FORM MEPS-10M(U) (4-20-2007)

PLAN INFORMATION – Continued
17a. Was hospital care covered under this plan?
155
1
Yes
2
No – SKIP TO 17d
17b. How much and/or what percentage of the total bill did an enrollee pay out-of-pocket
for an inpatient hospital admission at a participating hospital after any annual
deductible was met?
READ IF NECESSARY: Out-of-pocket expenses are those costs paid directly by the
enrollee. Some plans may have both a dollar copayment and a percentage
coinsurance. Report for precertified hospital admission, at an in-network/participating
hospital (if applicable). Do not include any physician charges incurred during the
hospital stay.
152

.00

Copayment paid by enrollee
for hospital admission

AND/OR
153

% Coinsurance by enrollee

17c. Was the copayment amount paid per day or per stay?
154
1
Per day
2
Per stay
17d. Was physician care covered under this plan?
218
1
Yes
2
No – SKIP TO 18
17e. How much and/or what percentage of the total bill did an enrollee pay out-of-pocket for
an office visit with a participating physician after any annual deductible was met?
READ IF NECESSARY: Out-of-pocket expenses are those costs paid directly by the
enrollee. Some plans may have both a dollar copayment and a percentage
coinsurance. Report for an in network/participating general practitioner during
normal office hours.
156

.00

Copayment

AND/OR
157

% Coinsurance
18.

Could this plan have refused to cover persons with pre-existing medical or health
conditions?
183
1
Yes
2
No

19.

Did this plan have a policy requiring a waiting period before covering pre-existing
conditions?
185
1
Yes
2
No

FORM MEPS-10M(U) (4-20-2007)

Page 7

PLAN INFORMATION – Continued
20.

Were prescription drugs covered under this health plan?
Yes
2
No
SKIP TO QUESTION 23
3
Don’t know
How many different pricing categories or tiers of prescription drug coverage were there
for this plan?
673

}

21.

712

Number of tiers
Don’t know

715

22.

How much and/or what percentage of the cost did an enrollee pay out-of-pocket for the
lowest tier of prescription drug coverage?
READ IF NECESSARY: Report for the least expensive pharmacy available to the enrollee
under the plan, excluding any mail-order programs.
655

.00

Copayment

AND/OR
677

% Coinsurance
23.

An employer can offer a Health Reimbursement Arrangement (HRA) by setting up an
account to reimburse employees for medical expenses not covered by health insurance.
Did your organization offer a Health Reimbursement Arrangement (HRA) associated with
this plan in 2006?
READ IF NECESSARY: HRAs are NOT Flexible Spending Accounts (FSAs) or Health
Savings Accounts (HSAs).
710

1
2
3

24.

Yes
No
Don’t know

Which of the following services were covered under this plan for the 2006 plan year:

173
587
176

Don’t
Yes No know
(1) (2) (3)

Chiropractic care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Routine vision care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Routine dental care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
END

• IF THERE IS A SECOND (OR THIRD) PLAN FOR THIS UNION –
GO TO ANOTHER MEPS-10M(U) QUESTIONNAIRE FOR THAT PLAN.
• IF THERE ARE NO MORE PLANS FOR THIS UNION – END THE INTERVIEW BY
READING THE THANK YOU STATEMENT.
THANK YOU
THIS CONCLUDES THE HEALTH INSURANCE COST STUDY. THANK YOU VERY MUCH
FOR YOUR TIME AND COOPERATION.
Page 8

FORM MEPS-10M(U) (4-20-2007)

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

Medical Expenditure Panel Survey – Insurance Component

HEALTH INSURANCE COST STUDY
Plan Information Questionnaire

Section B
HEALTH INSURANCE PLAN INSTRUCTIONS

The MEPS-11(C)S, Plan Information Questionnaire, has two columns per page.
One column is to be completed for EACH health insurance plan offered AT THIS
GOVERNMENT UNIT. Please use photocopies of the MEPS-11C(S) if sufficient plan
columns were not included in this reporting package.
Begin the first column of the questionnaire with the plan having the largest enrollment
and proceed through the columns to the plan with the smallest enrollment of ACTIVE
employees. Please enter the plan name at the top of each column.
ENROLLMENTS
Report enrollment figures for a typical pay period in 2006. Estimates are acceptable for
all enrollment figures. Include full-time, part-time, temporary, and seasonal
employees. Exclude retirees, former employees, and contract workers.
SINGLE coverage is health insurance coverage for the employee only.
EMPLOYEE-PLUS-ONE coverage is health insurance coverage for an
employee-plus-spouse or an employee-plus-child(ren) at a lower premium level
than family coverage. Enrollment totals for employee-plus-one should include
employees covered under employee-plus-spouse and employee-plus-child(ren).
PREMIUMS
Report premiums for TYPICAL situations and enrollees. If the premium varied, report
for a TYPICAL employee. Report government unit/employee contributions and total
premium for the same period in 2006. For a self-insured plan, report the premium
equivalent amount equal to the cost of the employee benefit.
SINGLE premium is the amount paid for coverage of one TYPICAL employee with
single coverage.
EMPLOYEE-PLUS-ONE premiums may differ for employee-plus-child(ren) and
employee-plus-spouse coverages. If this is the case, report for employee-plus-one child.
If premiums varied for other reasons, report for a TYPICAL employee.
FAMILY premiums may vary by family size. If this is the case, report for a family of four.
If there is an HSA or HRA associated with the plan, include any employer contribution
for an HSA or HRA account in the employer premium or total premium.

FORM

MEPS-11C(S)I (4-26-2007)

OMB No. 0935-0110: Approval Expires

GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
Answer questions 1–19 for each plan
offered. Begin with the plan having the
largest enrollment and proceed through to
the plan with the smallest enrollment of
ACTIVE employees.

100

012

FOR CENSUS USE ONLY

Name of plan

012

Name of plan

2006 ENROLLMENTS

1a.
b.
c.

125

Total ACTIVE employees ENROLLED
in plan

Total

ACTIVE employees ENROLLED in
SINGLE coverage

129

ACTIVE employees ENROLLED in
EMPLOYEE-PLUS-ONE coverage

571

Total
129

Single

Single
571

Employee + 1

See definition sheet for more information.

d.
2.

ACTIVE employees ENROLLED in
FAMILY coverage
FORMER employees ENROLLED through
PHSA (COBRA) or other state ContinuationOf-Benefits Laws, excluding retirees

705

Family
126

Former
PHSA (COBRA)

Family
126

Former
PHSA (COBRA)

2006 PREMIUMS

3a.

Single Coverage

552

Not offered – Skip to question 4a

Government/Employer contribution for
single premium

Employee contribution for single
premium

. 0 0

4a.

Government/Employer contribution for
employee-plus-one premium

Employee contribution for
employee-plus-one premium

FORM

Not offered – Skip to question 5a

636

570

. 0 0

570

Not offered – Skip to question 5a

. 0 0

637

635

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

. 0 0

636

637

Total employee-plus-one
premium

130

Total single premium

Employee-plus-one Coverage

132

130

Not offered – Skip to question 4a

131

552

635

Page 1

GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
100

FOR CENSUS USE ONLY
100

Name of plan

2006 PREMIUMS – Continued

5a.
b.

Family Coverage

137

Government/Employer contribution for
family premium

135

Employee contribution for family
premium

136

Total family premium

Not offered – Skip to question 6

135

. 0 0

136

134

The amounts reported in the
premium questions are based on
which of the following time
periods?

137

134

133

1
2

Weekly
Every 2 weeks

Monthly
Quarterly

Yearly

Coverage was underwritten by an
insurer – Skip to Question 9
Plan was self-insured – Continue
with Question 8a
Don’t know – Skip to Question 9

105

Coverage was underwritten by an
insurer – Skip to Question 9
Plan was self-insured – Continue
with Question 8a
Don’t know – Skip to Question 9

Yes – used TPA
No – self-administered
the plan

713

Yes
No

107

Mark (X) ONLY one.

133

Weekly
Every 2 weeks

SELF-INSURED PLAN INFORMATION

8a.

Was this plan purchased from an
insurance underwriter or was it
self-insured?
Coverage was underwritten by
the insurer (usually monthly) and the
insurer paid the enrollee’s claim.
The plan was self-insured for the
enrollee’s claim—either directly or
through a Third Party Administrator (TPA)
Complete questions 8a-b if this plan
was self-insured.
Did your government unit
employ a third party
administrator (TPA) for this
self-insured plan?
Did your government unit
purchase stop-loss coverage for
this plan?

105

2
3

713

1
2

107

1
2

2
3

1
2

Yes – used TPA
No – self-administered
the plan

Yes
No

Union

PLAN AFFILIATION

Was this plan offered through a
union or a trade association?

113

A trade association is a group of
individuals or companies in a specific
business or industry organized to
promote a common interest.

114

Name of union or trade association

114

Name of union or trade association

115

If a union, local number

115

If a union, local number

116

Name of insurance representative

116

Name of insurance representative

121

Telephone number

121

Telephone number

(

Page 2

Union

)

Trade 3
association

Neither

113

(

Trade 3
association

Neither

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

GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY

FOR CENSUS USE ONLY

100

Name of plan

Enter a two-digit numeric response.
Example: January=01; May=05

PLAN INFORMATION

10.

11.

12.

In what month did the plan
year begin?
Enter a two-digit numeric
response.
Example: January=01; May=05
Could this plan have refused
to cover persons with
pre-existing medical or
health conditions?

123

Month
183

1
2

Did this plan have a policy
requiring a waiting period
before covering pre-existing
conditions?

13.

123

185

1
2

Did the PREMIUMS CHARGED
by the insurance company or
carrier vary by any of these
employee characteristics?

138
139
141
142

If self-insured, mark (X) premiums
did not vary.
640

Mark (X) all that apply.

14.

Did the amount an
EMPLOYEE CONTRIBUTED
toward his/her own coverage
vary by any of these
employee characteristics?

641

Mark (X) all that apply.

706

642
643
644

645

646

Month

Yes
No

183

Yes
No

185

Age
Gender
Wage or salary level
Other
OR
Premiums did not vary

138

Hours worked
Union status
Wage or salary level
Occupation
Length of employment
Other
OR

641

Employee contribution did not vary

646

Yes
No

1
2

Yes
No

1
2

Age
Gender
Wage or salary level
Other
OR
Premiums did not vary

139
141
142

640

Hours worked
Union status
Wage or salary level
Occupation
Length of employment
Other
OR

642
643
644
706
645

Employee contribution did not vary

HEALTH SAVINGS ACCOUNT (HSA)

15a.

If the deductibles for this plan
were $1,050 or higher for
single coverage and $2,100 or
higher for family coverage, did
you contribute to a Health
Savings Account (HSA) for the
plan enrollees in 2006?
How much did the employer
contribute monthly to an
enrollee’s account for single
coverage?
How much did the employer
contribute monthly to an
enrollee’s account for family
coverage?
HSAs are NOT Flexible Spending
Accounts (FSAs) or Health
Reimbursement Arrangements
(HRAs). See definition sheet for
more information.

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

714

1
2
4

Yes, contributed to an HSA –
Continue with Question 15b
No, did not contribute to an HSA –
SKIP to Question 16
Don’t know – SKIP to Question 16

714

2
4

Monthly contribution for single HSA
716

Yes, contributed to an HSA –
Continue with Question 15b
No, did not contribute to an HSA –
SKIP to Question 16
Don’t know – SKIP to Question 16

Monthly contribution for single HSA
716

. 0 0

Monthly contribution for family HSA
717

. 0 0

Monthly contribution for family HSA
717

. 0 0

Page 3

GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100

FOR CENSUS USE ONLY
100

Name of plan

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

16.

An employer can offer a Health
Reimbursement Arrangement
(HRA) by setting up an account to
reimburse employees for medical
expenses not covered by health
insurance. Did your organization
offer a Health Reimbursement
Arrangement (HRA) associated
with this plan in 2006?

710

1
2
3

Yes
No
Don’t know

710

Yes – Skip to Question 18a
No

186

Replaced with similar plan
Replaced by a substantially
different plan
Enter New Plan name, then
continue with question 18a

187

Yes
No
Don’t know

1
2
3

HRAs are NOT Flexible Spending
Accounts (FSAs) or Health Reimbursement Arrangements (HRAs). See
definition sheet for more information.
CURRENT YEAR

17a.
b.

Is this plan being offered in
2007?

186

If this plan is no longer offered,
was it replaced with a similar
plan, replaced by a substantially
different plan or dropped
without replacement?

187

1
2
1
2

Yes – Skip to Question 18a
No

1
2
1
2

Replaced with similar plan
Replaced by a substantially
different plan
Enter New Plan name, then
continue with question 18a

707

Dropped without offering
replacement – Skip to "Please
Note" box on the next page.

2007 ENROLLMENTS

18a.
b.
c.
d.

In 2007, TOTAL ACTIVE
employees enrolled in PLAN

650

Total

In 2007, number of ACTIVE
employees enrolled in SINGLE
coverage

188

In 2007, number of ACTIVE
employees enrolled in
EMPLOYEE-PLUS-ONE coverage

584

In 2007, number of ACTIVE
employees enrolled in FAMILY
coverage

189

Total
188

Single

Single
584

Employee + 1

Employee + 1
189

Family

2007 PREMIUMS

19a.

190

In 2007, total monthly single
premium

. 0 0

649

In 2007, total monthly
employee-plus-one premium

In 2007, total monthly family
premium

Page 4

190

. 0 0

649

191

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

GENERAL PLAN INFORMATION – Continued

*** PLEASE NOTE ***
Complete a MEPS-11C(S) column for each plan that was offered.
If you have completed your last health insurance plan, continue
with form MEPS-11C(R), Section C.

REMEMBER TO ENCLOSE A COPY OF EACH PLAN BROCHURE WITH YOUR DATA SUBMISSION.

If you have any questions concerning this survey, please call 1–888–206–5068.
FORM MEPS-11C(S) (4-25-2007)

Page 5

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
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health insurance
plans offered in 2006 AT THIS GOVERNMENT UNIT. Please use photocopies of this MEPS-11(S)
form if sufficient copies were not included in this reporting package.

Section B
GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
Begin with the plan having the largest enrollment and
proceed through to the plan with the smallest enrollment
of ACTIVE employees.

100

Please photocopy this MEPS-11(S) questionnaire if
additional forms are needed.

For 2006, what was the name of the health
insurance plan with the largest (or next largest)
enrollment of ACTIVE employees?
Examples:

Name of plan
012

• Blue Cross Blue Shield, High Option
• Option A
• Aetna HMO

Which type of health care provider was available
through this plan?

103

Exclusive providers – Enrollees must go to providers
associated with the plan for all non-emergency care in order for
the costs to be covered.
Any providers – Enrollees may go to providers of their
choice with no cost incentives 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 providers
(Examples: Most PPO and POS-type plans)

1
2

Yes
No

Don’t Know

1
2

Union
Trade Association

Neither

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.

FORM

Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order to be
referred to a specialist?
For plans with multiple options, answer for the "in-network"
option.
Was this plan offered through a union or trade
association?

MEPS-11(S) (4-25-2007)

104

113

GENERAL PLAN INFORMATION – Continued

Was this plan purchased from an insurance
underwriter or was it self-insured?

105

1
2

Purchased from an insurance underwriter –
(Fully-insured) Coverage is purchased from an insurance
company or other underwriter who assumes the risk for
enrollees’ medical expenses.

Purchased – SKIP to Question 7a
Self-insured – Continue with Question 6a
Don’t know – SKIP to Question 7a

SELF-INSURED PLAN INFORMATION
Complete questions 6a–b if this plan was self-insured.

6a.

Did your organization employ a third party
administrator (TPA) for this self-insured plan?

Did your organization purchase stop-loss coverage
for this plan?

713

1
2

107

1
2

Yes – used a third party administrator
No – self-administered the plan

Yes
No

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.

7a.

How many ACTIVE employees were ENROLLED in
this plan at this government unit during a typical pay
period in 2006?

125

Active employees enrolled in
plan at this government unit

Include full-time, part-time, temporary and seasonal employees.
Exclude retirees, former employees, leased or contract
workers.

How many of those ACTIVE employees were
ENROLLED in SINGLE coverage during a typical pay
period in 2006?

129

Active employees enrolled in
single coverage

EMPLOYEE-PLUS-ONE coverage is health insurance coverage
for an employee-plus-spouse or an employee-plus-child(ren) AT
A LOWER PREMIUM than family coverage.

If your government unit offered EMPLOYEE-PLUS-ONE
coverage, how many ACTIVE employees were
ENROLLED during a typical pay period in 2006?

571

Active employees enrolled in
employee-plus-one coverage

Include enrollment for both employee-plus-spouse and
employee-plus-child(ren) coverage.

How many of those ACTIVE employees were
ENROLLED in FAMILY (i.e., not single or
employee-plus-one) coverage during a typical pay
period in 2006?

705

Active employees enrolled in
family coverage

PHSA (COBRA) ENROLLMENT

Page 2

How many FORMER employees were ENROLLED in
this plan, excluding retirees, through PHSA (COBRA)
or other State Continuation-Of-Benefits laws during a
typical pay period in 2006?

126

Former employees enrolled in plan,
excluding retirees

FORM MEPS-11(S) (4-25-2007)

PLAN PREMIUMS
Report for TYPICAL situations and enrollees.
If this was a self-insured plan, report the premium equivalent.
If premium varied, report for a TYPICAL employee.
Report government unit/employee contributions and total premium for the same period in 2006.
Include any subsidy from an outside third party in the employee contribution for premiums.
If there is an HSA or HRA associated with this plan, include any employer contributions to an HSA or
HRA account in the employer premium or total premium below.

SINGLE COVERAGE

9a.

552

Was SINGLE coverage offered under this plan?

Yes – Continue with Question 9b
No – SKIP to Question 10a

1
2

For this plan, how much did the GOVERNMENT
UNIT contribute toward the plan premium of one
typical employee with SINGLE coverage?

131

How much did this typical EMPLOYEE with
SINGLE coverage contribute toward his/her
own premium?

132

What was the TOTAL premium for this typical
employee with SINGLE coverage?

130

The amounts reported in questions 9b–d are based
on which one of the following time periods?
Mark (X) only one.

133

. 0 0

Government unit
contribution for
single premium

. 0 0

Employee
contribution for
single premium

. 0 0

Total single
premium

1
2

Weekly
Every 2 weeks

Monthly
Quarterly

Yearly

EMPLOYEE-PLUS-ONE COVERAGE
EMPLOYEE-PLUS-ONE coverage is health insurance
coverage for an employee-plus-spouse or an
employee-plus-child(ren) AT A LOWER PREMIUM LEVEL
than family coverage.
If employee-plus-one premiums were different for
employee-plus-child(ren) and employee-plus-spouse
coverages, report for employee-plus-one child. If premiums
varied for other reasons, report for a TYPICAL employee.

10a.
b.

Was EMPLOYEE-PLUS-ONE coverage offered under
this plan?
For this plan, how much did the GOVERNMENT UNIT
contribute toward the plan premium of one typical
employee with EMPLOYEE-PLUS-ONE coverage?

570

637

What was the TOTAL premium for this typical
employee with EMPLOYEE-PLUS-ONE coverage?

635

Mark (X) only one.

638

1
2
3
5
4

FORM MEPS-11(S) (4-25-2007)

. 0 0

Government unit
contribution for
employee-plus-one
premium

636

How much did this typical EMPLOYEE with
EMPLOYEE-PLUS-ONE coverage contribute toward
his/her own premium?

The amounts reported in questions 10b–d are based
on which one of the following time periods?

Yes – Continue with Question 10b
No – SKIP to Page 4, Question 11a

. 0 0

Employee
contribution for
employee-plus-one
premium

. 0 0

Total
employee-plus-one
premium

Weekly
Every 2 weeks
Monthly
Quarterly
Yearly
Page 3

PLAN PREMIUMS – Continued
FAMILY COVERAGE
If premium varied by family size, report for a family of four.

11a.

137

Was FAMILY coverage offered under this plan?

For this plan, how much did the GOVERNMENT UNIT
contribute toward the plan premium of one typical
employee with FAMILY coverage?

How much did this typical EMPLOYEE with FAMILY
coverage contribute toward his/her own premium?

d. What was the TOTAL premium for this typical
The amounts reported in questions 11b–d are based
on which one of the following time periods?

. 0 0

Government unit
contribution for
family premium

. 0 0

Employee
contribution for
family premium

. 0 0

Total family
premium

135

136

134

employee with FAMILY coverage?

Yes – Continue with Question 11b
No – SKIP to Question 12a

553

Weekly
Every 2 weeks

1
2

Mark (X) only one.

Monthly
Quarterly
Yearly

3
5
4

GENERAL PREMIUM INFORMATION

12a.

Did the PREMIUMS charged by the insurance
company or carrier vary by any of these
characteristics?

Age
Gender
Wage or salary levels
Other

138
139
141

Mark (X) all that apply.

142

Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?

640

Premiums did not vary

641

706

Hours worked
Union status
Wage or salary level
Occupation
Length of employment

645

Other

642
643

Mark (X) all that apply.

644

OR
Employee contribution did not vary

646

INDIVIDUAL DEDUCTIBLES

13a.

Did this plan have a deductible?
Deductible – Predetermined amount which must be
paid by an individual before the plan will reimburse for
covered services.

151

Yes – Continue with Question 13b
No – SKIP to Page 5, Question 16a

1
2

Many HMOs do not have a deductible.

What was the annual deductible an individual paid?
Report in-network deductibles (If applicable).
If separate deductibles apply, enter physician care and
hospital care amounts in appropriate boxes.
If deductible is per overnight hospital stay, it is
not an annual deductible and should be
reported under 16b on the next page.
DO NOT report COPAYMENTS or individual or family
maximums here.

Page 4

146

. 0 0

Individual annual
deductible

OR
Separate deductibles for:
147

. 0 0

Physician care

. 0 0

Hospital care

148

FORM MEPS-11(S) (4-25-2007)

FAMILY DEDUCTIBLES

14a.

Did this plan require that a specific number of
family members meet their individual deductibles
before the family deductible was met?

224

1
2
3

How many family members were required to
meet their individual deductibles before the
family deductible was met?

Yes – Continue with Question 14b
No – SKIP to Question 14c
Family coverage not offered – SKIP to Question 15a

150

Number of family members

Report for a family of four.

What was the total annual deductible a family
paid?

149

. 0 0

Total annual family
deductible

Report for a family of four.

HEALTH SAVINGS ACCOUNT (HSA)

15a.

b.
c.

If the deductibles you reported in questions 13
and 14 were $1,050 or higher for single coverage
and $2,100 or higher for family coverage, did you
contribute to a Health Savings Account (HSA) for
the plan enrollees in 2006?

714

How much did the employer contribute monthly
to an enrollee’s account for single coverage?

716

How much did the employer contribute monthly
to an enrollee’s account for family coverage?

717

1
2
4

Yes, contributed to an HSA – Continue with Question 15b
No, did not contribute to an HSA – SKIP to Question 16a
Don’t know – SKIP to Question 16a

. 0 0

Monthly contribution
for single HSA

. 0 0

Monthly contribution
for family HSA

HSAs are NOT Flexible Spending Accounts (FSAs),
or Health Reimbursement Arrangements (HRAs).
See definition sheet for more information.

PAYMENTS

16a.

Was hospital care covered under this plan?

155

Yes – Continue with Question 16b
No – SKIP to Question 16c

1
2

152

Was physician care covered under this plan?

218

$
154

1
2

FORM MEPS-11(S) (4-25-2007)

. 0 0

Copayment paid by enrollee
for hospital admission

Per day
Per stay
AND/OR

153

% Coinsurance
paid by enrollee

1
2

Yes – Continue with Question 16d
No – SKIP to Question 17 on Page 6

156

. 0 0

Copayment paid by enrollee
for office visit

AND/OR
157

% Coinsurance
paid by enrollee
Continue with Page 6, Question 17
Page 5

PAYMENTS – Continued

17.

Were prescription drugs covered under this
health plan?

673

Yes – Continue with Question 18
No
SKIP to Question 20a
Don’t know

}

2
3

18.

How many different pricing categories or tiers
of prescription drug coverage were there for
this plan?

712

Number of tiers
Don’t know

715

19.

How much and/or what percentage did an
enrollee pay out-of-pocket for the lowest
tier of prescription drug coverage?

Lowest cost to enrollee
655

. 0 0

Report for the least expensive pharmacy available to
the enrollee under the plan, excluding any mail-order
programs.

Copayment
And/Or
677

%
Coinsurance

20a.

Include all copayments, coinsurance and deductibles.
What was the MAXIMUM ANNUAL out-of-pocket
expense for an individual?
Out-of-pocket expense – Those costs paid directly by
the enrollee.

161

. 0 0

OR
No individual maximum

163

This is often referred to as a catastrophic limit.

What was the MAXIMUM ANNUAL out-of-pocket
expense for a family of four?

162

What was the MAXIMUM amount this plan would
have paid for an enrollee in ONE YEAR?

. 0 0

OR
No family maximum

222

21.

160

. 0 0

OR
No annual maximum

221

HEALTH REINBURSEMENT ARRANGEMENT (HRA)

22.

710

1
2
3

Yes
No
Don’t know

HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs).
See definition sheet for more information.

Page 6

FORM MEPS-11(S) (4-25-2007)

PLAN CHARACTERISTICS

23.
24.
25.

Could this plan have refused to cover persons
with pre-existing medical or health conditions?

183

Did this plan have a policy requiring a waiting
period before covering pre-existing conditions?

185

1
2

Yes
No
Yes
No

Which of the services listed were covered by
this plan?

Yes
(1)
173

Chiropractic care . . . . . . . . . . . . . . . . .

587

Routine vision care . . . . . . . . . . . . . . .

176

Routine dental care . . . . . . . . . . . . . . .

No
(2)

Don’t
know
(3)

*** PLEASE NOTE ***
If your government unit offered MORE THAN ONE health insurance plan, please fill out a
MEPS-11(s) for each plan that was offered. Then continue with the form MEPS-11(R), at the back
of this package.
If this is your last health insurance plan, please continue with the form MEPS-11(R), Section C.

FORM MEPS-11(S) (4-25-2007)

Page 7

U.S. DEPARTMENT OF COMMERCE

MEPS-15(S)I

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

(4-25-2007)

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

Medical Expenditure Panel Survey

PLAN INFORMATION QUESTIONNAIRES
A FEW IMPORTANT INSTRUCTIONS
This reporting package includes three blank MEPS-15(S), Plan Information
Questionnaires. Please report for a MAXIMUM of three representative plans
offered by your company. Definitions of the provided categories are at the
bottom of this page. Please use the following criteria to determine the plans for
which you should report.
•If your organization offered more than one Exclusive Provider Plan (HMO, IPA,
EPO) to its active employees and each plan offered a similar level of benefits
and/or premiums, complete only one MEPS-15(S) form for the Exclusive
Provider Plan with the largest enrollment.
•If your organization offered more than one Exclusive Provider Plan (HMO, IPA,
EPO) to its active employees and each plan offered a different level of
benefits and/or premiums, complete a MEPS-15(S) form for each of the two
plans which represent the two largest enrollments.
•If your organization offered more than one Mixture of Preferred and Any
Provider Plans (PPO, POS), e.g., high, standard, or low option, complete a
MEPS-15(S) form for each option where the level of benefits and/or premiums
differ.
•If your organization offered more than one Conventional or Indemnity Plan,
complete a MEPS-15(S) for the largest plan offered.
• Please retain a copy of the completed form for your records.
If you require assistance, please call 888–206–8023.

PROVIDER CATEGORIES
Exclusive Providers
(Examples: Most HMO, IPA, and EPO-type plans)
•Enrollees must go to providers associated with the plan for all non-emergency care in order for
the costs to be covered.
Any Providers
(Examples: Most fee-for-service plans)
•Enrollees may go to providers of their choice with no cost incentives to use a particular group of
providers.
Mixture of Preferred and Any Providers
(Examples: Most PPO and POS-type plans)
•Enrollees may go to any provider, but there is a cost incentive to use a particular group of
providers.

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
PLAN INFORMATION QUESTIONNAIRE

GENERAL PLAN INFORMATION
Please complete this Plan Information Questionnaire for the
representative plan with the largest (or next largest) enrollment.
Please select the plan which best represents all regions.

For 2006, what was the name of the health
insurance plan with the largest (or next largest)
national enrollment of ACTIVE employees?
Examples:

FOR CENSUS USE ONLY
100

012

Name of plan

103

• Blue Cross Blue Shield, High Option
• Company Plan A
• Aetna, HMO

Which type of health care provider was available
through this plan?

See the Definition Sheet included with this package for an
explanation of these plans.

Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order to be
referred to a specialist?

104

1
2
3

Exclusive providers
(Examples: Most HMO, IPA, and EPO-type plans)
Any providers
(Examples: Most fee-for-service plans)
Mixture of preferred and any providers
(Examples: Most PPO and POS-type plans)
Yes
No
Don’t Know

For plans with multiple options, answer for the "in-network"
option.

Was this plan offered through a union or trade
association?

113

1
2
3

Was this plan purchased from an insurance
underwriter or was it self-insured?

105

1
2

Purchased from an insurance underwriter –
(Fully-insured) Coverage is purchased from an insurance
company or other underwriter who assumes the risk for
enrollees’ medical expenses.
Self-insured – Your organization assumes the risk for the
enrollees’ medical expenses and may charge a premium to
employees. This plan may be administered by a third party
and may employ supplemental stop-loss insurance to limit
unanticipated losses.

Union
Trade association
Neither
Purchased – SKIP to Question 7a on Page 2
Self-insured – Continue with Question 6a
Don’t know – SKIP to Question 7a on Page 2

SELF-INSURED PLAN INFORMATION
Complete question 6a-b if this plan was self-insured.

6a.

Did your organization employ a third party
administrator (TPA) for this self-insured plan?

713

1
2

b.
FORM

Did your organization purchase stop-loss coverage
for this plan?

MEPS-15(S) (4-25-2007)

107

1
2

Yes – used a third party administrator
No – self-administered the plan
Yes
No
Page 1

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.

7a.

How many ACTIVE employees were ENROLLED in
this plan during a typical pay period in 2006?
Include full-time, part-time, temporary and seasonal employees.

125

Active employees enrolled in
plan

Exclude former employees, leased or contract workers and
retirees.

How many of these ACTIVE employees were
ENROLLED in SINGLE coverage during a typical pay
period in 2006?

129

Active employees enrolled in
single coverage

EMPLOYEE-PLUS-ONE coverage is health insurance coverage
for an employee-plus-spouse or an employee-pluschild(ren) AT A LOWER PREMIUM than family coverage.

If your organization offered EMPLOYEE-PLUS-ONE
coverage, how many ACTIVE employees were
ENROLLED during a typical pay period in 2006?
Include enrollment for both employee-plus-spouse and
employee-plus-child(ren) coverage.

571

How many ACTIVE employees were ENROLLED in
FAMILY (i.e., not single or employee-plus-one)
coverage during a typical pay period in 2006?

705

Active employees enrolled in
employee-plus-one coverage

ACTIVE employees enrolled in
family coverage

COBRA ENROLLMENT

How many FORMER employees were ENROLLED in
this plan, excluding retirees, through COBRA or
other State Continuation-Of-Benefits laws during a
typical pay period in 2006?

126

Former employees enrolled in plan,
excluding retirees

PLAN PREMIUMS
Report for TYPICAL situations and enrollees. If premium varied, report for a TYPICAL employee.
If this was a self-insured plan, report the premium equivalent.
Report employer/employee contributions and total premium for the same period during 2006.
Include any subsidy from an outside third party in the employee contribution for premiums.
If there is an HSA or HRA associated with this plan, include any employer contributions to an HSA
or HRA account in the employer premium or total premium below.

SINGLE COVERAGE
552

9a.

Was SINGLE coverage offered under this plan?

For this plan, how much did the EMPLOYER
contribute toward the plan premium of one typical
employee with SINGLE coverage?

131

How much did this typical EMPLOYEE with
SINGLE coverage contribute toward his/her
own premium?

132

What was the TOTAL premium for this typical
employee with SINGLE coverage?

130

The amounts reported in questions 9b–d are based
on which one of the following time periods?
Mark (X) only one.

133

Page 2

Yes – Continue with Question 9b
No – SKIP to Page 3, Question 10a

. 0 0

Employee
contribution for
single premium

. 0 0

Total single
premium

Weekly
Every 2 weeks

Monthly

. 0 0

Employer
contribution for
single premium

Quarterly

Yearly

FORM MEPS-15(S) (4-25-2007)

PLAN PREMIUMS – Continued
EMPLOYEE-PLUS-ONE COVERAGE
EMPLOYEE-PLUS-ONE coverage is health insurance coverage
for an employee-plus-spouse or an employee-plus-child(ren) AT
A LOWER PREMIUM than family coverage.
If employee-plus-one premiums were different for
employee-plus-child(ren) and employee-plus-spouse coverages,
report for employee-plus-one child. If premiums varied for other
reasons, report for a TYPICAL employee.

10a.
b.

Was EMPLOYEE-PLUS-ONE coverage offered under
this plan?
For this plan, how much did the EMPLOYER
contribute toward the plan premium of one
typical employee with EMPLOYEE-PLUS-ONE
coverage?

570

636

How much did this typical EMPLOYEE with
EMPLOYEE-PLUS-ONE coverage contribute toward
his/her own premium?

637

What was the TOTAL premium for this typical
employee with EMPLOYEE-PLUS-ONE coverage?

635

The amounts reported in questions 10b–d are based
on which one of the following time periods?

Yes – Continue with Question 10b
No – SKIP to Question 11a

638

. 0 0

Employee contribution for
employee-plus-one
premium

. 0 0

Total
employee-plus-one
premium

Weekly
Every 2 weeks

1
2

Mark (X) only one.

Employer
contribution for
employee-plus-one
premium

Monthly
Quarterly
Yearly

3
5
4

FAMILY COVERAGE
If premium varied by family size, report for a family of four.

11a.

Was FAMILY coverage offered under this plan?

137

Yes – Continue with Question 11b
No – SKIP to Page 4, Question 12a

1
2

For this plan, how much did the EMPLOYER
contribute toward the plan premium of one typical
employee with FAMILY coverage?

How much did this typical EMPLOYEE with FAMILY
coverage contribute toward his/her own premium?

d. What was the TOTAL premium for this typical

The amounts reported in questions 11b–d are based
on which one of the following time periods?
Mark (X) only one.

Employer
contribution for
family premium

. 0 0

Employee
contribution for
family premium

. 0 0

Total family
premium

134

553

1
2
3
5
4

FORM MEPS-15(S) (4-25-2007)

136

employee with FAMILY coverage?

. 0 0

135

Weekly
Every 2 weeks
Monthly
Quarterly
Yearly

Page 3

GENERAL PREMIUM INFORMATION

12a.

Did the PREMIUMS charged by the insurance
company or carrier vary by any of these
characteristics?

Age
Gender
Wage or salary levels
Other
OR

138
139
141

Mark (X) all that apply.

142

Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?

640

Premiums did not vary

641

644

Hours worked
Union status
Wage or salary level
Occupation

706

Length of employment

645

Other

646

Employee contribution did not vary

642
643

Mark (X) all that apply.

INDIVIDUAL DEDUCTIBLES

13a.

Did this plan have a deductible?
Deductible – Predetermined amount which must be
paid by an individual before the plan will reimburse
for covered services.

151

Yes – Continue with Question 13b
No – SKIP to Page 5, Question 16a

1
2

Many HMOs do not have a deductible.

What was the annual deductible an individual
paid?
Report "IN-NETWORK" deductibles (if applicable).
If separate deductibles apply, enter physician care and
hospital care amounts in appropriate boxes.
If deductible is per overnight hospital stay, it is not
an annual deductible and should be reported
under 16b on Page 5.
DO NOT report COPAYMENTS or individual or family
maximums here.

146

. 0 0

Individual annual
deductible

OR
Separate deductibles for:
147

. 0 0

Physician care

. 0 0

Hospital care

148

FAMILY DEDUCTIBLES

14a.

Did this plan require that a specific number of
family members must meet their individual
deductibles before the family deductible was met?

224

Yes – Continue with Question 14b
No – SKIP to Question 14c
Family coverage not offered –
SKIP to Page 5, Question 15a

1
2
3

How many family members were required to
meet their individual deductibles before the
family deductible was met?

150

Number of family members

Report for a family of four.

What was the total annual deductible a family
paid?

149

. 0 0

Total annual family
deductible

Report for a family of four.

Page 4

FORM MEPS-15(S) (4-25-2007)

HEALTH SAVINGS ACCOUNT (HSA)

15a.

If the deductibles you reported in questions 13
and 14 were $1,050 or higher for single coverage
and $2,100 or higher for family coverage, did you
contribute to a Health Savings Account (HSA) for
the plan enrollees in 2006?

714

How much did the employer contribute monthly
to an enrollee’s account for single coverage?

716

How much did the employer contribute monthly
to an enrollee’s account for family coverage?

717

1
2
4

Yes, contributed to an HSA – Continue with Question 15b
No, did not contribute to an HSA – SKIP to Question 16a
Don’t know – SKIP to Question 16a

. 0 0

Monthly contribution
for single HSA

. 0 0

Monthly contribution
for family HSA

HSAs are NOT Flexible Spending Accounts (FSAs),
or Health Reimbursement Arrangements (HRAs).
See definition sheet for more information.

PAYMENTS

16a.

Was hospital care covered under this plan?

155

Yes – Continue with Question 16b
No – SKIP to Question 16c

1
2

How much and/or what percentage of the total
bill did an enrollee pay out-of-pocket for an
inpatient hospital admission after any annual
deductible was met?

152

Out-of-pocket expense – Those costs paid directly by
the enrollee.

154

Some plans may have both a dollar copayment and a
percentage coinsurance.

$
1
2

. 0 0

Copayment paid by enrollee for
hospital admission

Per day
Per stay
AND/OR

153

Report for precertified hospital admissions (if applicable).

% Coinsurance paid by enrollee

Report for an admision at an "in-network"/participating
hospital (if applicable).
Do not include any physician charges incurred during the
hospital admission.

Was physician care covered under this plan?

218

1
2

Yes – Continue with Question 16d
No – SKIP to Question 17

156

. 0 0

Copayment paid by enrollee
for office visit

AND/OR
157

% Coinsurance paid by enrollee

Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for an "in-network"/participating general practitioner
during normal office hours.

17.

Were prescription drugs covered under this
health plan?

673

1
2
3

18.

How many different pricing categories or tiers
of prescripton drug coverage were there for this
plan?

}

712

715

FORM MEPS-15(S) (4-25-2007)

Yes – Continue with Question 18
No
SKIP to Page 6, Question 20a
Don’t know

Number of tiers
Don’t know

Page 5

PAYMENTS – Continued

19.

How much and/or what percentage did an
enrollee pay out-of-pocket for the lowest
tier of prescription drug coverage?

Lowest cost to enrollee
655

. 0 0

Report for the least expensive pharmacy available to
the enrollee under the plan, excluding any mail-order
programs.

Copayment

AND/OR
677

% Coinsurance
Include all copayments, coinsurance, and deductibles.

20a.

What was the MAXIMUM ANNUAL out-of-pocket
expense for an individual?

161

Out-of-pocket expense – Those costs paid directly by
the enrollee.

This is often referred to as a catastrophic limit.

163

What was the MAXIMUM ANNUAL out-of-pocket
expense for a family of four?

162

No individual maximum

What was the MAXIMUM amount this plan would
have paid for an enrollee in ONE YEAR?

. 0 0

OR
No family maximum

222

21.

. 0 0

160

. 0 0

OR
No annual maximum

221

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

22.

710

1
2
3

Yes
No
Don’t know

HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs).
See definition sheet for more information.

Page 6

FORM MEPS-15(S) (4-25-2007)

PLAN CHARACTERISTICS

23.

Could this plan have refused to cover persons
with pre-existing medical or health conditions?

183

1
2

24.
25.

Did this plan have a policy requiring a waiting
period before covering pre-existing conditions?

185

1
2

Yes
No

Which of the services listed were covered by this
plan?

Yes
(1)
173

Chiropractic care . . . . . . . . . . . . . .

587

Routine vision care . . . . . . . . . . . .

176

Routine dental care . . . . . . . . . . . .

No
(2)

Don’t
know
(3)

*** PLEASE NOTE ***
Please complete the MEPS-15(E) Establishment Worksheet when
you have completed all applicable MEPS-15(S) Plan Information
Questionnaires.
If your organization offered more than one health insurance plan,
please complete a Plan Information Questionnaire for each plan
that was offered, up to three plans.

FORM MEPS-15(S) (4-25-2007)

Page 7

File Type	application/pdf
File Modified	2007-09-27
File Created	2007-04-27