Form #3 Form #3 Plan Questionnaire

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

ATTACHMENT P -- Plan Questionnaire

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⚠️ Notice: This form may be outdated.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 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

2009 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2009 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 2009, 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 arrangement
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.

104

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

113

2
3

1
2
3

Union
Trade association
Neither
Continue with Page 2, Question 5

FORM

MEPS-10(S) (4-2-2009)

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
2009?

125

Active employees enrolled in
plan

129

Active employees enrolled in
single coverage

571

Active employees enrolled in
employee-plus-one coverage

705

Active employees enrolled in
family coverage

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 2009?
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 2009?
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 2009?

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 2009?

126

Former employees enrolled in plan,
excluding retirees

Continue with Page 3, Question 9a
Page 2

FORM MEPS-10(S) (4-2-2009)

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 2009.
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 contribution to the premium.

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?

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

. 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?

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) (4-2-2009)

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?

138

Age
Gender
Wage or salary levels

139
141
656

Mark (X) all that apply.

Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?
Mark (X) all that apply.

142

Composite rate plan
Other
OR

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
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) (4-2-2009)

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 15

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)

15.

If the deductibles you reported in questions 13 and
14 were $1,150 or higher for single coverage and
$2,300 or higher for family coverage, did you
contribute to a Health Savings Account (HSA) for
the plan enrollees in 2009?

714

1
2
4

Yes, contributed to an HSA
No, did not contribute to an HSA
Don’t know

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.

. 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
FORM MEPS-10(S) (4-2-2009)

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

SKIP to Question 20a

712

Number of tiers
715

19.

}

Don’t know
Lowest cost to enrollee

655

. 0 0

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 an HRA associated with this
plan in 2009?

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.
Continue with Page 7, Question 23

Page 6

FORM MEPS-10(S) (4-2-2009)

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) (4-2-2009)

Page 7

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
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health insurance
plans offered in 2009 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 2009, 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.

104

Was this plan offered through a union or trade
association?

113

MEPS-11(S) (4-2-2009)

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 2009?

125

Active employees enrolled in
plan at this government unit

129

Active employees enrolled in
single coverage

571

Active employees enrolled in
employee-plus-one coverage

705

Active employees enrolled in
family coverage

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 2009?
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 2009?
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 2009?

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 2009?

126

Former employees enrolled in plan,
excluding retirees

FORM MEPS-11(S) (4-2-2009)

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 2009.
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.

SINGLE COVERAGE

9a.
b.
c.
d.
e.

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?

570

For this plan, how much did the GOVERNMENT UNIT
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.

1
2
3
5
4

FORM MEPS-11(S) (4-2-2009)

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

. 0 0

Government unit
contribution for
employee-plus-one
premium

. 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.
b.
c.

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?

138

Age
Gender
Wage or salary levels
Composite rate plan
Other

139
141

Mark (X) all that apply.

656
142

640

Premiums did not vary

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

641

Mark (X) all that apply.

644
706

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

645

Other

642
643

OR
646

Employee contribution did not vary

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) (4-2-2009)

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 15

150

Number of family members

Report for a family of four.

149

What was the total annual deductible a family
paid?

. 0 0

Total annual family
deductible

Report for a family of four.

HEALTH SAVINGS ACCOUNT (HSA)

15.

If the deductibles you reported in questions 13
and 14 were $1,150 or higher for single coverage
and $2,300 or higher for family coverage, did you
contribute to a Health Savings Account (HSA) for
the plan enrollees in 2009?

714

1
2
4

Yes, contributed to an HSA
No, did not contribute to an HSA
Don’t know

PAYMENTS

16a.

Was hospital care covered under this plan?

155 1

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

152

Was physician care covered under this plan?

218 1

$
154 1
2

FORM MEPS-11(S) (4-2-2009)

. 0 0

Copayment paid by enrollee
for hospital admission

Per day
Per stay
AND/OR

153

% Coinsurance
paid by enrollee

156

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

. 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
715

19.

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

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

OR
No family maximum

222

21.

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

. 0 0

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) (4-2-2009)

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) (4-2-2009)

Page 7

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
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 2009. 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 2009. 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.

FORM

MEPS-11C(S)I (3-24-2009)

OMB No. 0935-0110: Approval Expires 05/31/2010

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. Report for a typical
pay period in 2009.

FOR CENSUS USE ONLY

100

012 Name of plan

125

2009 ENROLLMENTS

1a.
b.
c.

Total ACTIVE employees ENROLLED
in plan
ACTIVE employees ENROLLED in
SINGLE coverage
ACTIVE employees ENROLLED in
EMPLOYEE-PLUS-ONE coverage
Include both employee + spouse and
employee + child(ren).

Total
129

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)

2009 PREMIUMS

3a.

Single Coverage

552 2

Not offered – Skip to question 4a

Government/Employer contribution for
single premium

Employee contribution for single
premium

. 0 0

132

4a.

Total single premium

Employee-plus-one Coverage

Government/Employer contribution for
employee-plus-one premium

Employee contribution for
employee-plus-one premium

d.
FORM

570 2

Not offered – Skip to question 5a

. 0 0

570 2

Not offered – Skip to question 5a

. 0 0

637

635

MEPS-11C(S) (4-2-2009)

. 0 0

636

637

Total employee-plus-one
premium

130

636

132

130

Not offered – Skip to question 4a

131

552 2

635

Page 1

GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
100

FOR CENSUS USE ONLY
100

Name of plan

2009 PREMIUMS – Continued

5a.
b.

Family Coverage
Government/Employer contribution for
family premium

Employee contribution for family
premium

Total family premium

137

Not offered – Skip to question 6

135

Mark (X) ONLY one.

Not offered – Skip to question 6

135

. 0 0

136

. 0 0

136

134

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

137 2

134

133 1
2

133 1

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

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 1
2
3

713 1
2

107 1
2

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

2
3

Yes – used TPA
No – self-administered
the plan

713 1

Yes
No

107 1

Yes – used TPA
No – self-administered
the plan
Yes
No

PLAN AFFILIATION

Was this plan offered through a
union or a trade association?
A trade association is a group of
individuals or companies in a specific
business or industry organized to
promote a common interest.

113 1

Trade 3
association

Neither

113 1

Union

Trade 3
association

Neither

114 Name of union or trade association

115 If a union, local number

116 Name of insurance representative

121 Telephone number

(

Page 2

Union

)

(

)
FORM MEPS-11C(S) (4-2-2009)

GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY

FOR CENSUS USE ONLY

100

Name of plan

Enter a two-digit numeric response.

PLAN INFORMATION

10.

11.

12.

13.

In what month did the plan
year begin?
Enter a two-digit numeric
response.
Example: January=01; May=05

Example: January=01; May=05
123

Month

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

183 1

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

185 1

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

138
139
141

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

656
142

Month

Yes
No

183 1

Yes
No

185 1

Age
Gender
Wage or salary level
Composite rate plan
Other

138
139
141

Yes
No

Age
Gender
Wage or salary level
Composite rate plan
Other

656
142

Mark (X) all that apply.
OR

14.

Did the amount an
EMPLOYEE CONTRIBUTED
toward his/her own coverage
vary by any of these
employee characteristics?
Mark (X) all that apply.

640

Premiums did not vary

640

Premiums did not vary

641

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

641

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

642
643
644
706
645

OR
646

Employee contribution did not vary

OR
646

Employee contribution did not vary

714 1

Yes, contributed to an HSA

HEALTH SAVINGS ACCOUNT (HSA)

15.

If the deductibles for this
plan were $1,150 or higher
for single coverage and
$2,300 or higher for family
coverage, did you
contribute to a Health
Savings Account (HSA) for
the plan enrollees in 2009?

FORM MEPS-11C(S) (4-2-2009)

714 1

Yes, contributed to an HSA

No, did not contribute to an HSA

Don’t know

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 an HRA associated with this
plan in 2009?

710 1
2
3

Yes
No
Don’t know

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.

*** 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.
Page 4

FORM MEPS-11C(S) (4-2-2009)

U.S. DEPARTMENT OF COMMERCE

MEPS-15(S)I

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

(4-2-2009)

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

Health Insurance Cost Study

PLAN INFORMATION QUESTIONNAIRES
A FEW IMPORTANT INSTRUCTIONS
This reporting package includes four blank MEPS-15(S), Plan Information Questionnaires.
Please report for a MAXIMUM of four representative plans your organization offers. Definitions
of the provided categories are at the bottom of this page.
If your organization offers four plans or fewer, report for all plans. If your organization offers
more than four plans, please use the following criteria to determine which four plans to report.
• If your organization offers more than one Exclusive Provider Plan (HMO, IPA, EPO) to
its active employees and each plan offers 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 offers more than one Exclusive Provider Plan (HMO, IPA, EPO) to
its active employees and each plan offers 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 offers one or more Conventional or Indemnity Plan, complete a
MEPS-15(S) for the largest plan.
• If your organization offers more than one Mixture of Preferred and Any Provider Plans
(PPO, POS) to its active employees and each plan offers a different level of benefits
and/or premiums, complete a MEPS-15(S) form for each of the two plans which
represents the two largest enrollments.
• Please retain a copy of the completed form for your records.
If you require assistance, please call 888–206–8023, 8:30–5:00 EST.

PROVIDER ARRANGEMENT 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 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
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 2009, 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 arrangement 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 questions 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) (4-2-2009)

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 2009?
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 2009?

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.

571

How many ACTIVE employees were ENROLLED in
FAMILY (i.e., not single or employee-plus-one)
coverage during a typical pay period in 2009?

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 2009?

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 2009.
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 contribution to the premium.

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?

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) (4-2-2009)

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 1

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

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 1

. 0 0

Employee contribution for
employee-plus-one
premium

. 0 0

Total
employee-plus-one
premium

Weekly
Every 2 weeks

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 1

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

b.
c.

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

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

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

. 0 0

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) (4-2-2009)

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?
Mark (X) all that apply.

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

141

Age
Gender
Wage or salary levels

656

Composite rate plan

142

Other
OR

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

138
139

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 15

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) (4-2-2009)

HEALTH SAVINGS ACCOUNT (HSA)

15.

If the deductibles you reported in questions 13
and 14 were $1,150 or higher for single coverage
and $2,300 or higher for family coverage, did you
contribute to a Health Savings Account (HSA) for
the plan enrollees in 2009?

714

1
2
4

Yes, contributed to an HSA
No, did not contribute to an HSA
Don’t know

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

156

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

. 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) (4-2-2009)

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.

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

OR
No individual maximum

163

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.

. 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) (4-2-2009)

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)

No
(2)

Don’t
know
(3)

173 Chiropractic care . . . . . . . . . . . . . .
587 Routine vision care

. . . . . . . . . . . .

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

*** 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 four plans.

FORM MEPS-15(S) (4-2-2009)

Page 7

File Type	application/pdf
File Modified	2009-05-21
File Created	2009-04-03