Various Economic Pretesting Activities

OMB No. 0935-0110: Approval Expires 12/31/2014
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

2012 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2012 AT
THE LOCATION LISTED ABOVE.
Please use photocopies of this MEPS-10(S) form if sufficient copies were not included in this reporting
package.

GENERAL PLAN INFORMATION
If a plan name is preprinted in the Question 1 answer box below, answer for the plan specified. Otherwise, complete this
Plan Information Questionnaire for the plan with the largest (or next largest) enrollment of active employees.

1. For 2012, what was the name of the health

012 Name of plan

insurance plan with the largest (or next largest)
enrollment of ACTIVE employees?
Examples:

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

was available through this plan?

103
1

Exclusive providers
(Examples: Most HMO, IPA, and EPO-type
plans)

2

Any providers
(Examples: Most fee-for-service plans)

3

Mixture of preferred and any providers
(Examples: Most PPO and POS-type plans)

1

Yes

2

No

3

Don’t know

1

Union

2

Trade association

3

Neither

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.
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.

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3. Did this plan REQUIRE that the enrollee see a

104

gatekeeper or primary-care physician in order to
be referred to a specialist?
For plans with multiple options, answer for the "in-network"
option.

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

113

Continue with Page 2, Question 5
FORM MEPS-10(S) (03-01-2012)

§>#54¤

2. Which type of health care provider arrangement

2

GENERAL PLAN INFORMATION - Continued
5.

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

105

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

1

Purchased - SKIP to Question 7a

2

Self-insured - Continue with Question 6a

3

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

713

administrator (TPA) or purchase administrative
services only (ASO) from an insurer for this
self-insured plan?

b. Did your organization purchase stop-loss

1

Yes - Used a TPA or ASO

2

No - Self-administered the plan

1

Yes

2

No

107

coverage for this plan?

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.

7a. How many ACTIVE employees at this location

125

were ENROLLED in this plan during a typical
pay period in 2012?

Active employees enrolled
in plan

Include full-time, part-time, temporary and seasonal
employees.
Exclude former employees, leased or contract workers
and retirees.
129

ENROLLED in SINGLE coverage during a
typical pay period in 2012?

29022027

c.

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 EMPLOYEEPLUS-ONE coverage, how many ACTIVE
employees were ENROLLED during a typical
pay period in 2012?

571

Active employees enrolled
in single coverage

Active employees enrolled
in employee-plus-one
coverage

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

d. How many ACTIVE employees were ENROLLED

705

in FAMILY (not single or employee-plus-one)
coverage during a typical pay period in 2012?

Active employees enrolled
in family coverage

COBRA ENROLLMENT
8.

How many FORMER employees were ENROLLED
in this plan, excluding retirees, through COBRA
or state continuation-of-benefits laws during a
typical pay period in 2012?

FORM MEPS-10(S) (03-01-2012)

126

Former employees enrolled
in plan, excluding retirees
Continue with Page 3, Question 9a

§>#5<¤

b. How many of these ACTIVE employees were

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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 2012.
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

552

9a. Was SINGLE coverage offered under this plan?
b. For this plan, how much did the EMPLOYER
contribute toward the plan premium of one
typical employee with SINGLE coverage?

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

d. What was the TOTAL premium for this

1

Yes - Continue with Question 9b

2

No - SKIP to Question 10a
Employer

131

$

$

130

$

133

based on which one of the following time
periods?

,

single premium
Employee

132

typical employee with SINGLE coverage?

e. The amounts reported in Questions 9b-d are

.00 contribution for

.00 contribution for

,

single premium

.00 Total single

,

premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly

1

Yes - Continue with Question 10b

2

No - SKIP to Page 4, Question 11a

Mark (X) only one.

EMPLOYEE-PLUS-ONE 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.

570

10a. Was EMPLOYEE-PLUS-ONE coverage offered
under this plan?

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

29022035

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

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

e. The amounts reported in Questions 10b-d are
based on which one of the following time
periods?
Mark (X) only one.

Employer
contribution for
.00 employee-plus-one
premium

636

$

,

Employee
contribution for
.00 employee-plus-one
premium

637

$

,

Total

635

$
638

.00 employee-plus-one

,

premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly
Continue with Page 4, Question 11a

FORM MEPS-10(S) (03-01-2012)

§>#5D¤

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.

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PLAN PREMIUMS - Continued
FAMILY COVERAGE

137
1

Yes - Continue with Question 11b

2

No - SKIP to Question 12a

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

11a. Was FAMILY coverage offered under this plan?
b. For this plan, how much did the EMPLOYER

Employer

135

$

contribute toward the plan premium of one
typical employee with FAMILY coverage?

c. How much did this typical EMPLOYEE with

Employee

$

,

.00 contribution for
family premium

134

$

employee with FAMILY coverage?

e. The amounts reported in Questions 11b-d are

family premium

136

FAMILY coverage contribute toward his/her
own premium?

d. What was the TOTAL premium for this typical

,

.00 contribution for

,

553

based on which one of the following time
periods?

.00 Total family
premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly

Mark (X) only one.

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.

138

Age

139

Gender

141

Wage or salary levels

142

Other

b. 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

641

Hours worked

642

Union status

643

Wage or salary level

644

Occupation

706

Length of employment

645

Other

29022043

OR
Employee contribution did not vary

646

INDIVIDUAL DEDUCTIBLES
13a. Did this plan have a deductible?
Deductible - Predetermined amount which must be
paid by an individual before the plan will reimburse
for covered services.
Many HMOs do not have a deductible.

FORM MEPS-10(S) (03-01-2012)

151
1

Yes - Continue with Question 13b

2

No - SKIP to Page 5, Question 16a

§>#5L¤

OR

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INDIVIDUAL DEDUCTIBLES - Continued
13b. What was the annual deductible an individual

146

$

paid?
Report "IN-NETWORK" deductibles (if applicable).

deductible

OR
Separate deductibles for:

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
Question 16b below.

.00 Individual annual

,

147

$

.00

,

Physician care

148

$

DO NOT report COPAYMENTS or individual or family
out-of-pocket maximums here.

.00

,

Hospital care

FAMILY DEDUCTIBLES
14a. Did this plan require that a specific number

224

of family members meet their individual
deductibles before the family deductible
was met?

b. How many family members were required to
meet their individual deductibles before the
family deductible was met?
Report for a family of four.

c. What was the total annual deductible a family
paid?

1

Yes - Continue with Question 14b

2

No - SKIP to Question 14c

3

Family coverage not offered - SKIP to
Question 15

150

Number of family members

149

$

.00 Total annual family

,

Report for a family of four.

deductible

HEALTH SAVINGS ACCOUNT (HSA)
15.

If the deductibles you reported in Questions
13 and 14 were $1,200 or higher for single
coverage and $2,400 or higher for family
coverage, did your organization contribute
to a Health Savings Account (HSA) for the
plan enrollees in 2012?

714
1

Yes, contributed to an HSA

2

No, did not contribute to an HSA

4

Don’t know

16a. Was hospital care covered under this plan?

29022050

b. 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.

155

Report for an admission at an "in-network"/participating
hospital (if applicable).

Yes - Continue with Question 16b

2

No - SKIP to Page 6, Question 16c

152

$
154

Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).

1

.00

,

1

Per day

2

Per stay

Copayment paid by
enrollee for hospital
admission

AND/OR
153

%

Coinsurance
paid by enrollee

Do not include any physician charges incurred during
the hospital admission.

Continue with Page 6, Question 16c
FORM MEPS-10(S) (03-01-2012)

§>#5S¤

PAYMENTS

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PAYMENTS - Continued
16c. Was physician care covered under this plan?

d. How much and/or what percentage of the total

218
1

Yes - Continue with Question 16d

2

No - SKIP to Question 17

156

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

.00 Copayment paid by enrollee

$

bill did an enrollee pay out-of-pocket for an
office visit after any annual deductible was
met?

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

Yes

2

No
Don’t know

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

$

.00
Copayment

AND/OR
677

%

Coinsurance

Include all copayments, coinsurance and deductibles.
161

out-of-pocket expense for an individual?
Out-of-pocket expense - Those costs paid directly
by the enrollee.
This is often referred to as a catastrophic limit.

b. What was the MAXIMUM ANNUAL

.00

,

OR
163

No individual maximum

162

$

out-of-pocket expense for a family of four?
29022068

$

.00

,

OR
222

21.

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

No family maximum

160

$

,

,

.00

OR
221

No annual maximum

Continue with Page 7, Question 22
FORM MEPS-10(S) (03-01-2012)

§>#5e¤

20a. What was the MAXIMUM ANNUAL

7

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
22. An employer can offer a Health Reimbursement

710

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 2012?
HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs).

1

Yes

2

No

3

Don’t know

See definition sheet for more information.
|

PLAN CHARACTERISTICS
|
23. Could this plan have refused to cover persons

183

with pre-existing medical or health conditions?

24. Did this plan have a policy requiring a

1

Yes

2

No

1

Yes

2

No

185

waiting period before covering pre-existing
conditions?

25. Which of the services listed were covered by

Yes
(1)

this plan?

173

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

587

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

176

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

No
(2)

Don’t
know
(3)

*** PLEASE NOTE ***

29022076

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) (03-01-2012)

§>#5m¤

If your organization offered only one health insurance plan,
you have completed your response to this survey.