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pdfOMB No. 0935-0110: Approval Expires 1/31/2013
2011 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
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address: http://respond.census.gov/meps
RETURN TO
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001 OR
Fax to 1–800–447–4613
PLEASE RETURN ENTIRE PACKAGE WITHIN
PLEASE DO NOT REMOVE THIS COVER SHEET
FORM MEPS-10 (03-08-2011)
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29011012
Your Survey Key to access the Internet form is:
2
INSTRUCTIONS
1. Please report for the location identified on the cover sheet, unless
otherwise specified.
2. Please report data for the year 2011.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the definition sheet
included with this package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a completed copy of this form for your records.
7. If you have any questions or need assistance in completing the
questionnaire, please call
Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, per establishment, to complete the basic questionnaire. Establishments with
more than one health plan will take an additional 10 minutes per plan, on average, up to the maximum of four plans to be
reported. In addition, we estimate that it will take 15 minutes to review the instructions and locate the requested information.
You may send any comments regarding this burden estimate or any other aspect of the collection of information, including
suggestions for reducing burden, to the following address: Director, Center for Financing, Access and Cost Trends, Paperwork
Reduction Project 0935-0110, Agency for Healthcare Research and Quality, Room 5030, 540 Gaither Road, Rockville, MD
20850. Please do not mail questionnaires to this address as it will delay data processing. If the enclosed mailing envelope
has been misplaced, please use address on front page of form to return questionnaire.
FORM MEPS-10 (03-08-2011)
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29011020
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.
3
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 2011?
001
1
Yes – Continue with Question 2
2
No – SKIP to Section B
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 2011 plan year?
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 from the same
insurance company count as TWO plans.
Section B – HEALTH INSURANCE NOT OFFERED
Complete only if health insurance was NOT offered
during 2011; 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, 2006 and December 31,
2010?
031
What was the last year your organization offered
health insurance coverage to its employees at
this location?
032
1
Yes – Continue with Question 2
2
No – SKIP to Page 4, Section C
2 0
Last year offered
29011038
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Continue with Page 4, Section C
FORM MEPS-10 (03-08-2011)
4
Section C – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include officers, owners, full-time, 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 2011?
034
Employees at all locations
Complete questions 2–7 for THE LOCATION listed on
the cover sheet.
2a. How many employees were on your
200
All employees at this location
organization’s payroll AT THIS LOCATION
for a TYPICAL pay period in 2011?
b. How many of these employees were ELIGIBLE
If your organization did not offer health
insurance in 2011, SKIP to Question 3a
201
for at least one health plan through your
organization?
c. How many of these employees were ENROLLED
Eligible employees
202
in ANY health plan through your organization?
3a. For the same TYPICAL pay period in 2011, how
Enrolled employees
203
many of the employees reported in question C2a
worked part-time?
Part-time employees
If your organization did not offer health
insurance in 2011, SKIP to Question 5
204
ELIGIBLE for at least one health plan through
your organization?
c. How many of these part-time employees were
Eligible part-time employees
205
ENROLLED in ANY health plan through your
organization?
4.
Did your organization offer health insurance to
its temporary or seasonal employees at this
location in 2011?
Enrolled part-time employees
564
1
Yes
2
No
4
No temporary or seasonal employees
3
Don’t know
1
Information for specified location
2
Information for multiple locations
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Mark (X) only one.
5.
Is the information you provided in questions 2
and 3 above for the location listed on the cover
sheet OR did you provide information for
multiple locations?
550
If your organization did not offer health insurance
in 2011, SKIP to Page 5, Question 7a
6.
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?
FORM MEPS-10 (03-08-2011)
626
721
Minimum hours worked per week to be
eligible
No minimum number of hours required
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b. How many of these part-time employees were
5
Section C – EMPLOYMENT CHARACTERISTICS - Continued
Provide information for a TYPICAL pay period in 2011.
Estimates are acceptable.
The following workforce characteristics are used to group
similar organizations together for analytical purposes.
If none, enter "0".
7a. Approximately what percentage of the
016
%
employees at this location were women?
b. Approximately what percentage of the
017
employees at this location were 50 years old
or older?
c. Approximately what percentage of the
Women employees
%
Employees 50 years old or older
018
employees at this location were union members?
%
Union members
d. For the employees at this location in 2011,
approximately what percentage earned –
Less than $11.50 per hour? . . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
Between $11.50 and $26.50 per hour? . . . . . . . . . .
Approximately $24,000 to $55,000 a year
More than $26.50 per hour? . . . . . . . . . . . . . . . . . . .
Approximately $55,000 a year or more
022
%
Earned less than $11.50 per hour
%
Earned between $11.50 and $26.50
per hour
%
Earned more than $26.50 per hour
023
024
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Continue with Page 6, Section D
FORM MEPS-10 (03-08-2011)
6
Section D – BUSINESS CHARACTERISTICS
1a. Did your organization offer the following fringe
benefits to its employees at this location in
2011?
050
Paid vacation . . . . . . . . . . . . . . . . .
051
Paid sick leave . . . . . . . . . . . . . . .
052
Life insurance . . . . . . . . . . . . . . . .
053
Disability insurance . . . . . . . . . . . .
054
Retirement/pension plans . . . . . . . .
b. Did your organization offer any of these
tax-advantaged benefits to its employees at this
location in 2011?
See the definition sheet included with this package for an
explanation of these benefits.
These benefits are also known as Section 125 Cafeteria
plans.
627
Employee contributions to health
insurance made on a pre-tax basis
056
Flexible SPENDING Accounts
(FSA) for healthcare
057
Flexible Benefits Plans
Full cafeteria plans that offer
employees a set of benefits
from which to choose.
Yes
No
Don’t
know
(1)
(2)
(3)
Yes
No
Don’t
know
(1)
(2)
(3)
If your organization DID offer health insurance coverage to its
employees in 2011, continue to Page 7, Section E.
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If your organization DID NOT offer health insurance coverage to
its employees in 2011, SKIP to Page 8, Section F.
FORM MEPS-10 (03-08-2011)
7
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 2011 at a premium
SEPARATE from the comprehensive health plan
premium?
192
Dental
193
Vision
194
Prescription drugs
Do not include single services covered under a
comprehensive health plan.
195
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 Question 2a
Report single service insurance plans only.
}
Continue with Question 1b
Mark (X) all that apply.
720
coverage for all ACTIVE employees during a
TYPICAL MONTH at this location in 2011?
$
197
period before new employees could be covered
by health insurance?
b. For 2011, what was the TYPICAL waiting period?
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4.
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?
Did your organization provide any financial
compensation or incentives to employees if
they did not elect to receive health insurance
coverage?
.00
198
1
Yes – Continue with Question 2b
2
No – SKIP to Question 3
1
Less than 2 weeks
2
2 weeks to less than 1 month
5
Until the first day of the next month
3
1–3 months
4
More than 3 months
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
Mark (X) only one.
3.
,
Monthly optional coverage cost
Include both employer and employee contributions.
2a. For 2011, did your organization impose a waiting
,
722
723
Continue with Page 8, Section F
FORM MEPS-10 (03-08-2011)
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b. What was the total amount paid for optional
8
Section F – RETIREE HEALTH COVERAGE CHARACTERISTICS
Please complete questions 1–5 for ALL LOCATIONS.
Exclude any retirees that have coverage through COBRA
or state continuation-of-benefits laws. See the definition
sheet included with this package for an explanation of
these terms.
1.
Did your organization provide health
insurance coverage to any person who retired
in 2011 OR BEFORE, or to any of their survivors?
551
1
Yes – Continue with Question 2
2
No
3
Don’t know
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?
}
SKIP to Page 10, Section G
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
628
1
Yes – Continue with Question 3b
2
No – SKIP to Page 9, Question 4a
Question 2, under 65 years of age?
572
Number of retirees under 65
enrolled in health insurance
years of age were enrolled in health insurance
through your organization at all of its locations?
c. What percentage of these retirees were
573
% Retirees under 65 enrolled in
ENROLLED in SINGLE coverage?
d. For a typical plan in 2011, how much did the
single coverage
574
$
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with SINGLE
coverage?
e. For this same plan, what was the TOTAL monthly
$
.00
,
Total single premium
576
$
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
29011087
Employer contribution for
single premium
575
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2011, how much did the
.00
,
.00
,
Employer contribution for
family premium
For retirees, if premium varied by family size, report for a
family of two.
g. For this same plan, what was the TOTAL monthly
577
$
premium for this typical retiree with FAMILY
coverage?
h. Did a typical plan provide coverage for
outpatient prescription drugs for retirees
under 65 years of age?
724
.00
,
1
Yes
2
No
3
Don’t know
Total family premium
Continue with Page 9, Question 4a
FORM MEPS-10 (03-08-2011)
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b. In a typical month, how many retirees under 65
9
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.
629
4a. Were any of the enrolled retirees, reported in
1
Yes – Continue with Question 4b
2
No – SKIP to Question 5a
Question 2, 65 years of age or over?
b. In a typical month, how many retirees 65 years
578
Number of retirees 65 or over
enrolled in health insurance
of age or over were enrolled in health insurance
through your organization at all of its locations?
c. What percentage of these retirees were
579
% Retirees 65 or over enrolled in
ENROLLED in SINGLE coverage?
d. For a typical plan in 2011, how much did the
single coverage
580
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with SINGLE
coverage?
e. For this same plan, what was the TOTAL monthly
$
Employer contribution for
single premium
581
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2011, how much did the
.00
,
$
.00
,
Total single premium
582
$
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
.00
,
Employer contribution for
family premium
For retirees, if premium varied by family size, report for a
family of two.
g. For this same plan, what was the TOTAL monthly
583
premium for this typical retiree with FAMILY
coverage?
h. Did a typical plan provide coverage for
$
725
outpatient prescription drugs for retirees 65
years of age or over?
.00
,
Total family premium
1
Yes
2
No
3
Don’t know
1
Yes – Continue with Question 5b
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
For questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your organization in 2011.
630
Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.
5a. Did your organization offer health insurance to
29011095
any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
631
eligible for health insurance?
c. Were NEW RETIREES 65 years of age or over
632
eligible for health insurance?
}
SKIP to Page 10, Section G
Continue with Page 10, Section G
FORM MEPS-10 (03-08-2011)
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NEW RETIREES
10
500 Remarks
Section G – PERSON COMPLETING THIS QUESTIONNAIRE
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.
29011103
If your organization DID NOT offer health insurance, please complete
Section G and END the form.
212 Name (Please print)
213 Title (Please print)
214 Date (Month/Day/Year)
Signature
215 Telephone number
220 Extension 216 Fax
–
FORM MEPS-10 (03-08-2011)
–
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
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*** PLEASE NOTE ***
| File Type | application/pdf |
| File Title | meps10p01_11.g |
| File Modified | 2011-05-25 |
| File Created | 2011-03-08 |