Form #1 Form #1 Prescreener Questionnaire

2010 and 2011 Medical Expenditure Panel Survey - Insurance Componenet (MEPS-IC)

ATTACHMENT N -- Prescreener Questionnaire.wpd

Prescreener 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⚠️ Notice: This form may be outdated.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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Health Insurance Cost Study MPS-24

MEDICAL EXPENDITURE PANEL SURVEY

INSURANCE COMPONENT

ITEMS BOOKLET

2009 SURVEY YEAR

>INSAVAIL<

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

Did your organization make available or contribute to the cost of any health insurance plans for its ACTIVE employees at your [fill address] location in 2009?

(1) Yes

(2) No

>INSAVAIL_PROBE<

We include any coverage provided through a union, insurance carrier, professional association, or coverage self-insured by your organization. Did your organization make health insurance available through any of these methods in 2009?

(1) Yes

(2) No

>REFCONVERT<

This very important study is of national concern since it will have an impact on each and every one of our lives. It is very important that we have your cooperation to ensure the validity and accuracy of the data. Please be assured that all of your responses will be kept strictly confidential. May we please continue?

(1) Yes

(2) No

>MAYWEMAIL<

May I have the name of the contact person and mailing address where we can send the questionnaire?

(1) Yes

(2) No

>HOWMANYPLANS<

How many different health insurance plan choices did your organization make available or contribute to for its ACTIVE employees at your (fill address) location during the 2009 plan year?

READ IF NECESSARY: We only count comprehensive plans which cover hospital and/or physician coverage.

Single, employee-plus-one, and family coverage providing the same level of benefits are considered one plan. High and standard options under the same plan are considered 2 plans. An HMO and a conventional plan are considered 2 plans.

Number of Plans:

>STATEREPORT< (Govs)

Is there someone located at your government unit who would be able to provide information about the state sponsored health insurance plan(s) such as the type of provider arrangement, premiums, deductibles and enrollments?

(1) Yes

(2) No

>ZEROPLANPROBE<

The number of health plans should include any variety of options offered by a health insurance carrier which cover hospital stays and/or physician care. These options may cover differing levels of benefits.

Only comprehensive plans should be included.

Employers do not need to contribute to the plan premium in order for it to be counted.

Would you like to change your answer from the zero plans reported?

(1) Yes

(2) No

>LOCATIONEMP<

For this study, we define an "employee" as any worker for whom your organization withheld taxes including owners, part-time, and seasonal employees. We do not include former employees, leased or contract workers, or retirees.

Approximately, how many employees were on your organization's payroll at the location I mentioned earlier for a typical pay period in 2009?

Note: Do not attempt a new contact if this is the only item the respondent cannot answer.

Number of Employees:

>EMPZERO<

Please keep in mind that the period of reference for this study is a typical pay period in 2009. Include anyone for whom taxes were withheld. Include the owner as an employee if the owner works the majority of the time at this location. We also include all full- or part-time, temporary and seasonal employees as well as members of any union who are employed by your organization.

Would you like to change your answer from the zero employees reported?

(1) Yes

(2) No

>CP_NAME<, >CP_TITLE<, >CP_PHONE<, >CP_EXTN<

We will be mailing a questionnaire for this study to obtain information about the health insurance plans offered, such as health care provider options, premiums, and enrollment as well as other characteristics of your business such as fringe benefits and employee characteristics.

READ IF NECESSARY:

Are you the correct person to receive this questionnaire?

May I have the name, title and phone number of the Benefits Manager or other person to whom the questionnaire should be addressed?

Contact Person Name:

Contact Person Title:

Contact Person Phone:

Contact Person Extension:

>CPMAIL_MNAME1<, >CPMAIL_MNAME2<, >CPMAIL_MSTREET1<, >CPMAIL_MSTREET2<, >CPMAIL_PLACE<, >CPMAIL_STATE<, >CPMAIL_ZIP5<, >CPMAIL_ZIP4<

READ IF NECESSARY:

What is your mailing address, starting with your organization’s name?

What is (fill contact person’s name) mailing address, starting with the organization’s name?

Mail CoName1:

Mail CoName2:

Mail Street1:

Mail Street2:

Mail City: Mail State: Mail Zip:

>FC_COUNTRY<

Enter the foreign country.

Country:

>FC_POSTALCODE<

Enter the foreign postal code.

Postal Code:

>PLANNAMES<

We would like to send labeled questionnaires requesting detailed information on your organization's health insurance plans.

Please provide me with the names of the [fill number of plans] health insurance plans your organization made available to its active employees in 2009 in order of enrollment, naming the plan with the largest enrollment of active employees first.

Press F10 if New Contact Needed.

If there is a union plan, but the respondent is unable to provide the name of the plan, enter “Union Plan” to hold the place for the union plan data collection.

Enter 999 if No More Plans can be named.

HEALTH PLAN NAME:

>SPELLING_REVIEW<

Review the list of plan names. Do you need to make any changes?

(List of plan names)

(1) No Changes Needed

(2) Change the number of plans

(3) Add, Edit, Delete plan names

>CHANGENUMPLANS<

Current number of plans: (Number of plans)

We only count comprehensive plans which cover hospital and/or physician coverage.

Single, employee-plus-one, and family coverage providing the same level of benefits are considered one plan.

High and standard options under the same plan are considered 2 plans.

An HMO and a conventional plan are considered 2 plans.

Enter the New number of Plans:

>NOINSAVAIL<

READ IF NECESSARY:

In order to make our study representative, we need to ask a few more questions of those establishments which did NOT make insurance available in 2009.

These questions include: some general questions about the classification of employees, the types of employees, and the fringe benefits offered.

>NOINSLAST5YEARS<

Did your organization offer any health insurance as a benefit to its employees at the location I mentioned earlier between January 1, 2004 and December 31, 2008?

READ IF NECESSARY:

(fill address)

(1) Yes

(2) No

>LASTYEARINSOFFERED<

What was the last year your organization offered health insurance coverage to its employees?

Year

>MORETHAN1LOCATION<

Does your organization have more than one location?

(1) Yes

(2) No

>TOTALEMPALL<

For this study, we define an "employee" as any worker for whom your organization withheld taxes, including owners, part-time, and seasonal employees. We do not include former employees, leased or contract workers, or retirees.

Approximately how many total employees did your organization have at ALL locations for a TYPICAL pay period in 2009?

Number of Employees:

>LOCATIONEMP<

Approximately, how many employees were on your organization's payroll at the location I mentioned earlier for a typical pay period in 2009?

Number of Employees:

>EMPZERO<

Would you like to change your answer from the zero employees reported?

(1) Yes

(2) No

>EMPCLASS_INTRO<

The next set of questions will ask about different employee classifications. Estimates or percentages are acceptable where numeric replies are needed.

>PARTTIMEGOV< (Govs)

Did your government unit have any part-time employees in 2009?

(1) Yes

(2) No

>DEMOCHARS_PARTTIME_NUM<

How many of the (fill LOCATIONEMP) employees at this location were part-time?