Download:
pdf |
pdfOMB No. 0935-0110: Approval Expires 05/31/2010
2009 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
(4-2-2009)
OR
INSTRUCTIONS
1. Please report for the location identified on the cover sheet, unless
otherwise specified.
2. Please report data for the year 2009.
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
Collection of this information is authorized under Section 913 of the Public Health Service Act
(Title 42 United States Code, Section 299b-2). Section 9 of Title 13, United States Code (the U.S.
Census Bureau Statute), ensures that the information you report to us will be strictly confidential.
It may be seen only by individuals sworn to uphold U.S. Census Bureau confidentiality and may
be used only for statistical purposes.
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 (4-2-2009)
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 2009?
001 1
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 2009 plan year?
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
2009; 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, 2004 and December 31, 2008?
What was the last year your organization offered
health insurance coverage to its employees at this
location?
031
1
2
032
Yes – Continue with Question 2
No – SKIP to Page 4, Section C
2 0
Last year offered
Continue with Page 4, Section C
FORM MEPS-10 (4-2-2009)
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 2009?
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 2009?
200
All employees at this location
If your organization did not offer health insurance in
2009, 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 2009, how
many of the employees reported in question C2a
worked part-time?
203
Eligible employees
Enrolled employees
Part-time employees
If your organization did not offer health insurance in
2009, 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 2009?
564
Eligible part-time employees
Enrolled part-time employees
Mark (X) only one.
5.
6.
Page 4
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 company offered health insurance,
what is the minimum number of hours per
week that an employee must work in order 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
2009, SKIP to Page 5, Question 7a.
721
Minimum hours worked per
week to be eligible
No minimum number of hours required
FORM MEPS-10 (4-2-2009)
Section C – EMPLOYMENT CHARACTERISTICS – Continued
Provide information for a TYPICAL pay period in 2009.
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 2009,
approximately what percentage earned –
Less than $11.00 per hour? . . . . . . . . . . . . . . . . . .
Approximately $22,880 a year or less
Between $11.00 and $25.50 per hour? . . . . . . . . . .
Approximately $22,880 to $53,040 a year
More than $25.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $53,040 a year or more
022
023
024
%
%
%
%
%
%
Women employees
Employees 50 years old or older
Union members
Earned less than $11.00 per hour
Earned between $11.00 and $25.50 per hour
Earned more than $25.50 per hour
Continue with Page 6, Section D
FORM MEPS-10 (4-2-2009)
Page 5
Section D – BUSINESS CHARACTERISTICS
1a.
Did your organization offer the following fringe
benefits to its employees at this location in 2009?
050
051
052
053
054
b.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
627
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.
These benefits are also known as Section 125 Cafeteria plans.
057
Approximately how many years has your
organization been in business?
If your organization operates at more than one location,
enter the number of years the parent company has been in
business.
588
1
2
3
Less than 1 year
1–2 years
3–4 years
4
5
6
No
Don’t
know
(1)
(2)
(3)
Yes
No
Don’t
know
(1)
(2)
(3)
.
.
.
.
.
Did your organization offer any of these
tax-advantaged benefits to its employees at this
location in 2009?
See the definition sheet included with this package for an
explanation of these benefits.
2.
Paid vacation . . . . . . . .
Paid sick leave . . . . . . .
Life insurance . . . . . . . .
Disability insurance . . . .
Retirement/pension plans
Yes
5–9 years
10–19 years
20 years or more
If your organization DID offer health insurance coverage to its
employees in 2009, continue to Page 7, Section E.
If your organization DID NOT offer health insurance coverage to
its employees in 2009, SKIP to Page 8, Section F.
Page 6
FORM MEPS-10 (4-2-2009)
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 2009 at a premium
SEPARATE from the comprehensive health plan
premium?
Report single service insurance plans only.
192
}
195
Dental
Vision
Prescription drugs
Long-term care
562
No optional coverage – SKIP to Question 2a
193
194
Continue with Question 1b
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 during a
TYPICAL MONTH at this location in 2009?
720
$
b.
For 2009, did your organization impose a waiting
period before new employees could be covered by
health insurance?
197
For 2009, what was the TYPICAL waiting period?
198
1
2
Mark (X) only one.
1
2
5
3
4
3.
4.
,
. 0 0
Monthly optional coverage cost
Include both employer and employee contributions.
2a.
,
Did your organization place any limits or
restrictions on health insurance coverage for the
spouse of an employee, if the spouse had access
to coverage through another employer?
722
Did your organization provide any financial
compensation or incentives to employees, if they
did not elect to receive health insurance
coverage?
723
1
2
3
1
2
3
Yes – Continue with Question 2b
No – SKIP to Question 3
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
Yes
No
Don’t know
Yes
No
Don’t know
Continue with Page 8, Section F
FORM MEPS-10 (4-2-2009)
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.
Does your organization provide health
insurance coverage to any person who retired
in 2009 OR BEFORE, 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 a typical month, how many retirees were
enrolled in health insurance through your
organization at all of its locations?
513
Number of 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 F2, under 65 years of age?
628
b.
In a typical month, how many retirees under 65
years of age were enrolled in health insurance
through your organization at all of its locations?
572
c.
What percentage of these retirees were
ENROLLED in SINGLE coverage?
573
d.
For a typical plan in 2009, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE coverage?
e.
f.
g.
h.
Yes – Continue with Question 3b
No – SKIP to Page 9, Question 4a
1
2
Number of 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 2009, 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
Did a typical plan provide coverage for outpatient
prescription drugs for retirees under 65 years of
age?
724
1
2
3
$
,
. 0 0
Employer contribution
for single premium
$
,
. 0 0
Total single
premium
$
,
. 0 0
Employer contribution
for family premium
$
,
. 0 0
Total family
premium
Yes
No
Don’t know
Continue with Page 9, Question 4a
Page 8
FORM MEPS-10 (4-2-2009)
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.
Were any of the enrolled retirees, reported in
Question F2, 65 years of age or over?
629
In a typical month, how many retirees 65 years of
age or over were enrolled in health insurance
through your organization at all of its locations?
578
c.
What percentage of these retirees were
ENROLLED in SINGLE coverage?
579
d.
For a typical plan in 2009, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE coverage?
b.
e.
2
Number of retirees 65 or over
enrolled in health insurance
Retirees 65 or over enrolled in single
% 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 2009, 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
g.
For this same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?
583
h.
Did a typical plan provide coverage for outpatient
prescription drugs for retirees 65 years of age or
over?
725
f.
Yes – Continue with Question 4b
No – SKIP to Question 5a
1
1
2
3
$
,
. 0 0
Employer contribution
for single premium
$
,
. 0 0
Total single
premium
$
,
. 0 0
Employer contribution
for family premium
$
,
. 0 0
Total family
premium
Yes
No
Don’t know
NEW RETIREES
For questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your organization in 2009.
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
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
FORM MEPS-10 (4-2-2009)
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 Name (Please print)
213 Title
214 Date (Month/Day/Year)
M M
D D
Y
Y
Y
Signature
215 Telephone number
(
Page 10
)
220 Extension 216 FAX number
(
Y
217 E-Mail address
)
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-10 (4-2-2009)
OMB No. 0935-0110: Approval Expires 05/31/2010
2009 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)
(4-2-2009)
OR
INSTRUCTIONS
1. Please report for the government unit identified on the cover sheet.
2. Please report data for the year 2009.
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) (4-2-2009)
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 2009?
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 2009 plan
year?
003
Number of Health Plans offered
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
Continue with Section B on MEPS-11(S)
REMARKS
FORM MEPS-11(F) (4-2-2009)
Page 3
OMB No. 0935-0110: Approval Expires 05/31/2010
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
Does your government unit or some other
government unit provide health insurance coverage
to any person who retired from your government unit
in 2009 OR BEFORE, or to any of their survivors?
If PHSA (COBRA) was the only coverage offered mark "No".
Enter name of other government unit
Continue with Question 2 if information is available.
Otherwise SKIP to Page 3, Section D.
551
No
Don’t know
2
3
2.
In a typical month, how many retirees were
enrolled in health insurance through your
government unit?
}
SKIP to Page 3, Section D.
513
Number of retirees enrolled
UNDER 65 YEARS OF AGE
Exclude any retirees that have coverage through
PHSA (COBRA) or state continuation-of-benefits laws.
If this was a self-insured plan, report the premium equivalent.
3a.
628
Were any of the enrolled retirees reported in
Question 2, under 65 years of age?
Yes – Continue with Question 3b
No – SKIP to Question 4a on Page 2
1
2
b.
In a typical month, how many retirees under 65
years of age were enrolled in health insurance
through your government unit?
572
c.
What percentage of those retirees were
ENROLLED in SINGLE coverage?
573
Number of retirees under 65
enrolled in health insurance
% Retirees under 65
enrolled in single coverage
d.
e.
f.
g.
h.
For a typical plan in 2009, how much did the
GOVERNMENT UNIT contribute toward the monthly
plan premium for one typical retiree with SINGLE
coverage?
574
For that same plan, what was the TOTAL monthly
premium for this typical retiree with SINGLE
coverage?
575
For a typical plan in 2009, 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
For that same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?
577
Did a typical plan provide coverage for outpatient
prescription drugs for retirees under 65 years of
age?
724
1
2
3
FORM
MEPS-11(R) (3-24-2009)
$
,
. 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
Yes
No
Don’t know
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.
Were any of the enrolled retirees reported in
Question 2, 65 years of age or over?
629
b.
In a typical month, how many retirees 65 years or
over were enrolled in health insurance through
your government unit?
578
c.
What percentage of those retirees were
ENROLLED in SINGLE coverage?
579
4a.
Yes – Continue with Question 4b
No – SKIP to Question 5a
1
2
Number of retirees 65 years or over
enrolled in health insurance
% Retirees 65 years or over enrolled in
single coverage
d.
e.
f.
g.
h.
For the 2009 plan with the largest enrollment, how
much did the GOVERNMENT UNIT contribute
toward the monthly plan premium for one typical
retiree with SINGLE coverage?
580
For that same plan, what was the TOTAL monthly
premium for this typical retiree with SINGLE
coverage?
581
For the 2009 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
Did a typical plan provide coverage for outpatient
prescription drugs for retirees 65 years of age?
725
1
2
3
$
,
. 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
Yes
No
Don’t know
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 2009.
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) (3-24-2009)
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 2009 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.
192
}
195
Dental
Vision
Prescription drugs
Long-term care
562
No optional coverage – SKIP to Question 2a
193
194
Continue with Question 1b
Mark (X) all that apply.
b.
2a.
b.
What was the total amount paid for optional
coverage for all ACTIVE employees at THIS
GOVERNMENT UNIT during a typical month
in 2009?
720
For 2009, did your government unit impose a
waiting period before new employees could be
covered by health insurance?
197
For 2009, what was the typical waiting period?
198
$
,
,
. 0 0
Monthly optional coverage cost
Yes – Continue with Question 2b
No – SKIP to Section E
1
2
Mark (X) only one.
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
1
2
5
3
4
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
for a typical pay period in 2009?
201
How many of those ACTIVE employees were
ENROLLED in ANY health plan through your
government unit?
202
For the same typical pay period in 2009, did your
government unit have any part-time employees?
563
Eligible employees
Enrolled employees
1
2
3
b.
c.
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 2009?
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, what is the minimum number of
hours per week that an employee must work in
order to be eligible for health insurance?
FORM MEPS-11(R) (3-24-2009)
Yes – Continue with Question 2b
⎫
No
⎬ SKIP to Question 3
Don’t know ⎭
Yes
No
No temporary or seasonal employees
Don’t know
626
Minimum hours worked per
week to be eligible
721
No minimum number of hours required
Page 3
Section F – FRINGE BENEFITS CHARACTERISTICS
1.
Did your government unit offer the following fringe
benefits to its employees in 2009?
Paid vacation . . . . . . . .
Paid sick leave . . . . . . .
Life insurance . . . . . . . .
Disability insurance . . . .
Retirement/pension plans
050
051
052
053
054
2.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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 2009?
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 2009.
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
2009, approximately what percentage earned –
022
Less than $11.00 per hour? . . . . . . . . . . . . . . . . . .
Approximately $22,880 a year or less
023
Between $11.00 and $25.50 per hour? . . . . . . . . . .
Approximately $22,880 to $53,040 a year
024
%
%
%
%
%
More than $25.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $53,040 a year or more
Women employees
Employees 50 years old or older
Union members
Earned less than $11.00 per hour
Earned between $11.00 and $25.50 per hour
Earned more than $25.50 per hour
Section H – PERSON COMPLETING THIS QUESTIONNAIRE
212 Name (Please print)
213 Title
214 Date (Month/Day/Year)
M M
D D
Y
Y
Y
Signature
215 Telephone number
(
Page 4
)
220 Extension 216 FAX number
(
Y
217 E-Mail address
)
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-11(R) (3-24-2009)
OMB No. 0935-0110: Approval Expires 05/31/2010
2009 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
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address: http://harvester.census.gov/meps
Your User ID to access the Internet form is:
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) (4-2-2009)
INSTRUCTIONS
1. Please report for the government unit identified on the cover
sheet.
2. Report data for the year 2009.
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) (4-2-2009)
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 2009?
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 2009 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 Name (Please print)
Signature
215 Telephone number
(
)
FORM MEPS-11C(F) (4-2-2009)
213 Title
214 Date (Month/Day/Year)
M M
D D
Y
Y
Y
670 Brochure Website address
http: //
220 Extension 216 FAX number
(
217 E-Mail address
)
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
Y
OMB No. 0935-0110: Approval Expires 05/31/2010
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 in
2009 from your government unit, 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 a TYPICAL month, how many retirees
were enrolled in health insurance through
your government unit?
No
Don’t know
}
SKIP to Section D.
513
Number of retirees enrolled
CONTINUE WITH QUESTION 3a ON NEXT PAGE
FORM
MEPS-11C(R) (4-2-2009)
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.
3a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Exclude any retirees that have coverage
through PHSA (COBRA) or state
continuation-of-benefits-laws.
Were any of the retirees with coverage,
reported in Question 2, under 65 years of
age or age 65 years or over?
UNDER 65 YEARS OF AGE
628
In a TYPICAL MONTH, what was the
TOTAL number of retirees, by age
category, enrolled in health insurance
through your government unit in 2009?
572
What percentage of those retirees, by
age category, were ENROLLED in
SINGLE coverage?
573
For the 2009 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 2009 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.
1
Yes
2
No
AGE 65 YEARS OR OVER
629
1
Yes
2
No
578
Total under 65
Total 65 or over
579
% Percent enrolled
% Percent enrolled
in single
574
580
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
651
For that same plan, what was the TOTAL
monthly premium, by age category, for this
typical retiree with FAMILY coverage?
577
Did a typical plan provide coverage for
outpatient prescription drugs for
retirees?
724
,
. 0 0
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
$
,
. 0 0
581
576
652
$
653
575
For that same plan, how much did this
typical RETIREE with FAMILY coverage
CONTRIBUTE, by age category, toward
his/her monthly plan premium?
in single
582
654
583
1
2
3
725
Yes
No
Don’t know
1
2
3
Yes
No
Don’t know
NEW RETIREES
4a.
For Questions 4a through 4c, NEW RETIREES
refers to persons who retired from your
government unit in 2009.
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?
b. Were NEW RETIREES under 65 years of
630
1
2
3
631
age eligible for health insurance?
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) (4-2-2009)
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 2009 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
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
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 during a TYPICAL
MONTH at THIS GOVERNMENT UNIT in 2009?
720
$
,
,
. 0 0
Monthly 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 2009?
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 2009?
563
Eligible employees
Enrolled employees
1
2
3
b.
c.
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 2009?
564
Enrolled part-time employees
Mark (X) only one.
1
4
3
If your government unit offered health insurance,
what is the minimum number of hours per week
that an employee must work in order to be eligible
for health insurance?
}
Eligible part-time employees
2
4.
Yes – Continue with Question 2b
No
SKIP to Question 3
Don’t know
626
721
Yes
No
No temporary or seasonal employees
Don’t know
Minimum hours worked
per week to be eligible
No minimum number of hours required
If you have questions or need assistance,
call us toll-free at 1–888–206–5068.
FORM MEPS-11C(R) (4-2-2009)
Page 3
Section F – FRINGE BENEFITS CHARACTERISTICS
1.
Did your government unit offer the following fringe
benefits to its employees in 2009?
Yes
(1)
No
(2)
Don’t
know
(3)
Yes
(1)
No
(2)
Don’t
know
(3)
050 Paid vacation . . . . . . . . . . . . . . . .
051 Paid sick leave . . . . . . . . . . . . . . .
052 Life insurance . . . . . . . . . . . . . . .
053 Disability insurance . . . . . . . . . . . .
054 Retirement/pension plans . . . . . . . .
2.
Did your government unit offer any of these
tax-advantaged benefits to its employees in 2009?
See definition sheet included with this package for an
explanation of these benefits.
627 Employee contributions to health
These plans are also known as Section 125 Cafeteria Plans.
056 Flexible SPENDING account (FSA)
insurance made on a pre-tax basis
for healthcare
057 Flexible Benefits Plans
Full cafeteria plans that offer employees
a set of benefits from which to choose
Section G – EMPLOYEE CHARACTERISTICS
Provide information for a TYPICAL pay period in
2009.
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.
Approximately what percentage of the employees
at this government unit were WOMEN?
016
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
2009, approximately what percentage EARNED –
022
Less than $11.00 per hour? . . . . . . . . . . . . . . . . .
Approximately $22,880 a year or less
023
Between $11.00 and $25.50 per hour? . . . . . . . . .
Approximately $22,880 to $53,040 a year
More than $25.50 per hour? . . . . . . . . . . . . . . . . .
Approximately $53,040 a year or more
024
%
%
%
%
%
%
Women employees
Employees 50 years old or older
Union members
Earned less than $11.00 per hour
Earned between $11.00 and $25.50 per hour
Earned more than $25.50 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) (4-2-2009)
OMB No. 0935-0110: Approval Expires 05/31/2010
2009 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
(4-2-2009)
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 2009.
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
Collection of this information is authorized under Section 913 of the Public Health Service Act
(Title 42 United States Code, Section 299b-2). Section 9 of Title 13, United States Code (the U.S.
Census Bureau Statute), ensures that the information you report to us will be strictly confidential.
It may be seen only by individuals sworn to uphold U.S. Census Bureau confidentiality and may
be used only for statistical purposes.
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 (4-2-2009)
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 2009 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 2009?
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.
How many different health insurance choices
did your company make available or contribute
to for its ACTIVE employees at a TYPICAL
location during the 2009 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 (4-2-2009)
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 2009?
034
Employees at all locations
If your company did not offer health
insurance in 2009, 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 2009,
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 2009, 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
2009?
564 1
Eligible part-time employees
Enrolled part-time employees
2
4
Mark (X) only one.
4.
Page 4
If your company offered health insurance, what
is the minimum number of hours per week that
an employee must work in order to be eligible
for health insurance?
3
626
721
Yes
No
No temporary or seasonal employees
Don’t know
Minimum hours worked per
week to be eligible
No minimum number of hours required
FORM MEPS-15 (4-2-2009)
Section B – EMPLOYMENT CHARACTERISTICS – Continued
5.
Of the active employees enrolled in a health
insurance plan your company offered in 2009,
what percentage were ENROLLED in each of the
following provider arrangements?
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)
520
Mixture of preferred and any
% providers (Examples: Most PPO
and POS-type plans)
Provide information for a TYPICAL pay period in 2009.
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 2009,
approximately what percentage earned –
022
Less than $11.00 per hour? . . . . . . . . . . . . . . . .
Approximately $22,880 a year or less
Between $11.00 and $25.50 per hour? . . . . . . .
Approximately $22,880 to $53,040 a year
More than $25.50 per hour? . . . . . . . . . . . . . . . .
Approximately $53,040 a year or more
FORM MEPS-15 (4-2-2009)
023
024
%
%
%
Earned less than $11.00 per hour
Earned between $11.00 and $25.50
per hour
Earned more than $25.50 per hour
Page 5
Section C – BUSINESS CHARACTERISTICS
1a.
Did your company offer the following fringe
benefits to its employees in 2009?
Mark (X) all that apply.
050
Paid vacation . . . . . . . .
Paid sick leave . . . . . . .
Life insurance . . . . . . . .
Disability insurance . . . .
Retirement/pension plans
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 Benefit 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 2009?
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
2009, SKIP to Page 9, Section F
Page 6
FORM MEPS-15 (4-2-2009)
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.
Did your company provide health insurance
coverage to any person who retired in 2009 OR
BEFORE, or to any of their survivors?
551
Yes – Continue with Question 2
No
SKIP to Page 9, Section E
Don’t know
1
}
2
3
2.
In a typical month, how many retirees were
enrolled in health insurance through your
company?
513
Number of 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.
In a typical month, how many retirees under 65
years of age were enrolled in health insurance
through your company at all of its locations in 2009?
572
c.
What percentage of these retirees were
ENROLLED in SINGLE coverage?
573
d.
For a typical plan in 2009, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
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 2009, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
576
e.
f.
Yes – Continue with Question 3b
No – SKIP to Page 8, Question 4a
1
2
Number of 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
For retirees, if premium varied by family size, report for a family
of two.
g.
h.
For this same plan, what was the TOTAL monthly
premium for this typical retiree with FAMILY
coverage?
577
Did a typical plan provide coverage for outpatient
prescription drugs for retirees under 65 years of
age?
724
1
2
3
FORM MEPS-15 (4-2-2009)
Yes
No
Don’t know
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.
In a typical month, how many retirees 65 years of
age or over were enrolled in health insurance
through your company in 2009?
578
c.
What percentage of these retirees were
ENROLLED in SINGLE coverage?
579
d.
For a typical plan in 2009, how much did the
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with
SINGLE 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 2009, 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
Did a typical plan provide coverage for outpatient
prescription drugs for retirees under 65 years of age
or over?
725
e.
f.
g.
h.
Yes – Continue with Question 4b
No – SKIP to Question 5a
1
2
Number of retirees 65 or over
enrolled in health insurance
Retirees 65 or over enrolled in single
% coverage
1
2
3
$
,
. 0 0
Employer
contribution for
single premium
$
,
. 0 0
Total single
premium
$
,
. 0 0
Employer
contribution for
family premium
$
,
. 0 0
Total family
premium
Yes
No
Don’t know
NEW RETIREES
For questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your organization in 2009.
Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.
5a.
Did your company 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 (4-2-2009)
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 2009 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
Do not include single services covered under a
comprehensive health plan.
562
No optional coverage – SKIP to Question 2a
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 during a
TYPICAL MONTH, at your company in 2009?
Include both employer and employee contributions.
2a.
b.
720
4.
,
. 0 0
Monthly optional coverage cost
For 2009, did your company impose a waiting
period before new employees could be covered
by health insurance?
197 1
For 2009, what was the TYPICAL waiting
period?
198 1
2
Mark (X) only one.
3.
,
$
Did your company place any limits or
restrictions on health insurance coverage for
the spouse of an employee, if the spouse had
access to coverage through another employer?
722
Did your company provide any financial
compensation or incentives to employees, if
they did not elect to receive health insurance
coverage?
723
Yes – Continue with Question 2b
No – SKIP to Question 3
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
Yes
No
Don’t know
2
3
1
2
3
Yes
No
Don’t know
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 four.
If your company DID NOT offer health insurance, please complete Section
F and SKIP to the attached MEPS-15(E), Establishment Worksheet.
212 Name (Please print)
213 Title
214 Date (Month/Day/Year)
M M
D D
Y
Y
Y
Signature
215 Telephone number
(
)
FORM MEPS-15 (4-2-2009)
220 Extension 216 FAX number
(
Y
217 E-Mail address
)
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
Page 9
500 Remarks
Page 10
FORM MEPS-15 (4-2-2009)
OMB No. 0935-0110: Approval Expires 05/31/2010
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
2009. 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)
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
MEPS-15(E) (4-2-2009)
(d)
1
YES
2
NO
Types of provider
arrangements offered
(Mark (X) all that apply)
HMO/
EPO
Conventional
Indemnity
(f)
PPO/
POS
200
(e)
521
522
(g)
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
(c)
524
FORM
Number
of
employee(s)
CENSUS USE ONLY
Location
identification number
(a)
Name of location
Have you
answered
for this
location on
the
MEPS-15?
(b)
1
YES
2
NO
524
1
YES
2
NO
524
1
YES
2
NO
524
1
YES
2
NO
524
1
2
Types of provider
arrangements offered
(Mark (X) all that apply)
200
HMO/
EPO
(e)
521
Conventional
Indemnity
(f)
522
PPO/
POS
(g)
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
(d)
(c)
524
YES
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) (4-2-2009)
Number
of
employee(s)
1
YES
2
NO
| File Type | application/pdf |
| File Modified | 2009-05-21 |
| File Created | 2009-04-03 |