Various Governments Pretesting Activites

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

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.
Did your government unit or some other
government unit provide health insurance
coverage to any person who RETIRED
from your government unit in 2012 OR
BEFORE, or to any of their survivors?

1

Yes – This government unit – Continue with Question 2

4

Yes – Another government unit
➤

1.

551

672

Enter name of other government unit
Continue with Question 2 if information is
available. Otherwise Skip to Section D.

If PHSA (COBRA) was the only coverage offered,
mark "No".

2.

In a TYPICAL month, how many retirees
were enrolled in health insurance through
your government unit?

551
2

No

3

Don’t know

}

SKIP to Section D

513

Number of retirees enrolled

29082013

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Continue with Page 2, Question 3a

FORM MEPS-11C(R) (03-08-2012)

2

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 OR OVER.

3a.

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?

b. In a TYPICAL MONTH, what was the

1

Yes

2

No

573

Percent

No

Total 65 or over
579

Percent

% enrolled

in single

in single

580

574

$

,

.00

651

$

.00

,

653

$

,

.00

$

.00

,

581

575

monthly premium, by age category, for
this typical retiree with SINGLE coverage?

g. For a typical plan in 2012, how much did

2

% enrolled

typical RETIREE with SINGLE coverage
CONTRIBUTE, by age category, toward
his/her monthly plan premium?

f. For this same plan, what was the TOTAL

Yes

Total under 65

the GOVERNMENT UNIT CONTRIBUTE, by
age category, toward the monthly plan
premium for one typical retiree with
SINGLE coverage?

e. For this same plan, how much did this

1

578

age category, were ENROLLED in SINGLE
coverage?

d. For a typical plan in 2012, how much did

629

572

TOTAL number of retirees, by age
category, enrolled in health insurance
through your government unit in 2012?

c. What percentage of these retirees, by

AGE 65 YEARS OR OVER

UNDER 65 YEARS OF AGE
628

$

,

$

.00

.00

,

582

576

the GOVERNMENT UNIT CONTRIBUTE, by
age category, toward the monthly plan
premium for one typical retiree with
FAMILY coverage?

$

,

.00

$

.00

,

For retirees, if premium varied by family size,
report for a family of two.
654

652

typical RETIREE with FAMILY coverage
CONTRIBUTE, by age category, toward
his/her monthly plan premium?

i. For this same plan, what was the TOTAL

$

$
724

outpatient prescription drugs for retirees?

$

.00

,

583

577

monthly premium, by age category, for
this typical retiree with FAMILY coverage?

j. Did a typical plan provide coverage for

,

.00

,

1

Yes

2

$

.00
725

.00

,

1

Yes

No

2

No

3

Don’t know

3

Don’t know

1

Yes – Continue with Question 4b

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

29082021

NEW RETIREES
For Questions 4a through 4c, NEW RETIREES
refers to persons who retired from your government
unit in 2012.

630

Exclude any retirees that have coverage
through PHSA (COBRA) or state
continuation-of-benefits-laws.

4a. Did your government unit offer health
insurance to any NEW RETIREES?

b. Were NEW RETIREES under 65 years of

631

age eligible for health insurance?

c. Were NEW RETIREES 65 years of age or
over eligible for health insurance?
FORM MEPS-11C(R) (03-08-2012)

632

}

SKIP to Section D

§>)56¤

h. For this same plan, how much did this

3

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 2012 at a premium SEPARATE from
the comprehensive health plan premium?
Report single service insurance plans only.
Long-term care insurance helps cover the cost of institutional
and home care required by the chronically ill or disabled.

192

Dental

193

Vision

194

Prescription drugs

Do not include single services covered under a
comprehensive health plan.
Mark (X) all that apply.

195

Long-term care

562

No optional coverage – SKIP to Section E

b. What was the total amount paid for OPTIONAL

Continue with Question 1b

720

COVERAGE for all ACTIVE employees during a
TYPICAL MONTH at THIS GOVERNMENT UNIT in
2012?
Include both employee and government unit contributions.

$

,

,

.00

Monthly optional coverage cost

Section E – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility, and
enrollment figures.
Include full-time, part-time, temporary, and seasonal
employees.
201

at least one health plan through your government
unit in 2012?

b. How many of these ACTIVE employees were

Eligible employees
202

ENROLLED in ANY health plan through your
government unit?

2a. Did your government unit have any PART-TIME

Enrolled employees
563

employees in 2012?

1

Yes – Continue with Question 2b

2

No

3

b. How many of these PART-TIME employees were

Don’t know

Eligible part-time employees
205

ENROLLED in ANY health plan through your
government unit?

3.

Did your government unit offer health insurance
to its temporary or seasonal employees in 2012?

Enrolled part-time employees
564

29082039

Mark (X) only one.

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?

SKIP to Question 3

204

ELIGIBLE for at least one health plan through your
government unit?

c. How many of these PART-TIME employees were

}

1

Yes

2

No

4

Government unit has no temporary
or seasonal employees

3

Don’t know

626

Minimum hours worked
per week to be eligible
721

No minimum number of hours required

Continue with Page 4, Section F
FORM MEPS-11C(R) (03-08-2012)

§>)5H¤

1a. How many ACTIVE employees were ELIGIBLE for

4

Section F – FRINGE BENEFITS CHARACTERISTICS
1.

2.

Did your government unit offer the following
fringe benefits to its employees in 2012?
050

Paid vacation . . . . . . . . . . . . . . . . .

051

Paid sick leave . . . . . . . . . . . . . . . .

052

Life insurance . . . . . . . . . . . . . . . . .

053

Disability insurance . . . . . . . . . . . . .

054

Retirement/pension plans. . . . . . . . .

Did your government unit offer any of these
tax-advantaged benefits to its employees in
2012?
See the definition sheet included with this package for an
explanation of these benefits.
These plans 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)

Section G – EMPLOYEE CHARACTERISTICS
Provide information for a TYPICAL pay period in
2012.
Estimates are acceptable.
The following workforce characteristics are used to group
similar government units together for analytical purposes.

1.

Approximately what percentage of the employees
at this government unit were union members?

018

%

Union members

729

No union members

2.

Approximately what percentage of the employees
at this government unit were women?

016

%

If none, enter "0".

3.

Approximately what percentage of the employees
at this government unit were 50 years old or
older?

Women employees

017

%

Employees 50 years old or older

If none, enter "0".

29082047

4.

For the employees at this government unit in
2012, approximately what percentage earned –
Less than $11.50 per hour?. . . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
Between $11.50 and $27.00 per hour? . . . . . . . . . . .
Approximately $24,000 to $56,000 a year

022

%
023

%

For the employees at this government unit in
2012, approximately how many earned more
than $40.00 per hour?
Approximately $83,000 a year or more

FORM MEPS-11C(R) (03-08-2012)

Earned between $11.50 and $27.00
per hour

024

%

More than $27.00 per hour? . . . . . . . . . . . . . . . . . . . .
Approximately $56,000 a year or more

5.

Earned less than $11.50 per hour

726

Earned more than $27.00 per hour

Number of employees that
earned more than $40.00 per hour

§>)5P¤

If none, enter "0".