Various Governments Pretesting Activites

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

Section B – GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
Answer Questions 1-16 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 2012.

FOR CENSUS USE ONLY

100

100

012 Name of plan

012 Name of plan

Total ACTIVE employees ENROLLED
in plan

125

125

ACTIVE employees ENROLLED in
SINGLE coverage

129

2012 ENROLLMENTS

1a.
b.

Total

Total
129

Single

Single

c.

ACTIVE employees ENROLLED in
EMPLOYEE-PLUS-ONE coverage

571

571

Employee + 1

Employee + 1

Include both employee + spouse and
employee + child(ren).
See definition sheet for more information.

d.

ACTIVE employees ENROLLED in
FAMILY coverage

705

705

Family

Family

2.

FORMER employees ENROLLED
through PHSA (COBRA) or state
continuation-of-benefits laws, excluding
retirees

126

126

Former
PHSA (COBRA)

Former
PHSA (COBRA)

2012 PREMIUMS

b.

c.

Single Coverage

552

Not offered - Skip to Question 4a

2

Government/Employer contribution for
single premium

131

Employee contribution for single premium

132

29072014

4a.

,

b.

c.

d.

570

,

Employee contribution for
employee-plus-one premium

637

Total employee-plus-one
premium

FORM MEPS-11C(S) (03-02-2012)

$

.00

,

$

.00

Not offered - Skip to Question 5a

2

636

,

.00

,

.00

130

$

Government/Employer contribution for
employee-plus-one premium

$

.00
132

$

Total single premium

Employee-plus-one Coverage

Not offered - Skip to Question 4a

2

131

$

130

d.

552

570

,

.00

Not offered - Skip to Question 5a

2

636

$

,

$

.00

,

.00

637

$

,

$

.00

635

,

.00

635

$

,

.00

$

,

.00

§>(5/¤

3a.

2

Section B – GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100

FOR CENSUS USE ONLY
100

Name of plan

Name of plan

2012 PREMIUMS - Continued

5a. Family Coverage
b. Government/Employer contribution for

137

135

,

.00

,

$

.00

,

134

.00

,

134

$
133

Mark (X) ONLY one.

$
136

$

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

Not offered - Skip to Question 6

2

.00

136

premium

6.

137

135

$

family premium

c. Employee contribution for family

Not offered - Skip to Question 6

2

$

.00

,

1

Weekly

5

Quarterly

2

Every 2
weeks

4

Yearly

3

Monthly

1

Coverage was underwritten
by an insurer - Skip to
Question 9

2

133

.00

,

1

Weekly

5

Quarterly

2

Every 2
weeks

4

Yearly

3

Monthly

1

Coverage was underwritten
by an insurer - Skip to
Question 9

Plan was self-insured Continue with Question 8a

2

Plan was self-insured Continue with Question 8a

3

Don’t know - Skip to
Question 9

3

Don’t know - Skip to
Question 9

1

Yes - Used TPA or ASO

1

Yes - Used TPA or ASO

2

No - Self-administered the plan

2

No - Self-administered the plan

1

Yes

1

Yes

2

No

2

No

1

Union

1

Union

2

Trade Association

2

Trade Association

3

Neither

3

Neither

7.

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

105

Coverage was underwritten by
an insurer and the insurer paid the
enrollee’s claim.
The plan was self-insured if
government paid enrollee’s claim
directly or through a third party
administrator (TPA).

29072022

8a.

Complete Questions 8a-b if this plan
was self-insured.
Did your government unit
employ a third party
administrator (TPA) or purchase
administrative services only
(ASO) from an insurer for this
self-insured plan?

b. Did your government unit

713

107

purchase stop-loss coverage for
this plan?

105

713

107

PLAN AFFILIATION

9.

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.

FORM MEPS-11C(S) (03-02-2012)

113

113

§>(57¤

SELF-INSURED PLAN INFORMATION

3

Section B – GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100

FOR CENSUS USE ONLY
100

Name of plan

Name of plan

PLAN INFORMATION

10. In what month did the plan

Enter a two-digit numeric response.

year begin?

Enter a two-digit numeric response.

Example: January=01; May=05
123

Example: January=01; May=05
123

Month

11. Could this plan have refused to

183

cover persons with pre-existing
medical or health conditions?

12. Did this plan have a policy

13. Did the PREMIUMS CHARGED by
the insurance company or carrier
vary by any of these employee
characteristics?
If self-insured, mark (X) premiums did
not vary.

1

Yes

2

No

1

Yes

2

No

185

requiring a waiting period
before covering pre-existing
conditions?

Month
183
1

Yes

2

No

1

Yes

2

No

185

138

Age

138

Age

139

Gender

139

Gender

141

Wage or salary level

141

Wage or salary level

142

Other

142

Other

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?

OR

640

Premiums did not vary

640

Premiums did not vary

641

Hours worked

641

Hours worked

642

Union status

642

Union status

643

Wage or salary level

643

Wage or salary level

644

Occupation

644

Occupation

706

Length of Employment

706

Length of Employment

645

Other

645

Other
OR

OR
646

FORM MEPS-11C(S) (03-02-2012)

Employee contribution did
not vary

646

Employee contribution did
not vary

§>(5?¤

29072030

Mark (X) all that apply.

4

GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100

FOR CENSUS USE ONLY
100

Name of plan

Name of plan

HEALTH SAVINGS ACCOUNT (HSA)
15. If the deductibles for this plan

714

were $1,200 or higher for single
coverage and $2,400 or higher
for family coverage, did your
government unit contribute to a
Health Savings Account (HSA)
for the plan enrollees in 2012?

1

Yes, contributed to an HSA

2

4

714
1

Yes, contributed to an HSA

No, did not contribute to an
HSA

2

No, did not contribute to an
HSA

Don’t know

4

Don’t know

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
government unit offer an HRA
associated with this plan in
2012?

710

710
1

Yes

No

2

No

Don’t know

3

Don’t know

1

Yes

2

3

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.

REMEMBER TO ENCLOSE A COPY OF EACH PLAN BROCHURE OR PROVIDE THE BROCHURE
WEBSITE ADDRESS WITH YOUR CONTACT INFORMATION ON THE MEPS-11C(F). PLEASE PROVIDE
THE GENERAL USER INFORMATION IN THE REMARKS SECTION.

If you have any questions concerning this survey, please call 1-888-206-5068.
FORM MEPS-11C(S) (03-02-2012)

§>(5Q¤

29072048

If you have completed your last health insurance plan, continue
with form MEPS-11C(R), Section C.