Form #1 Form #1 Prescreener Questionnaire

ATTACHMENT A

Prescreener Questionnaire

Form Approved
OMB No. 0935-0110
Exp. Date XX/XX/20XX

Health Insurance Cost Study MPS-24

MEDICAL EXPENDITURE PANEL SURVEY

INSURANCE COMPONENT

JOB AID 2

ITEMS BOOKLET

2011 SURVEY YEAR

Public reporting burden for this collection of information is estimated to average 5 ½ minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

>INSAVAIL<

For this study, a health insurance plan is hospital and/or physician coverage made available to employees.

Did your organization make available or contribute to the cost of any health insurance plans for its ACTIVE employees at your [fill address] location in 2011?

(You told me earlier that you do not offer insurance. We include any coverage provided through a union, insurance carrier, professional association or coverage self-insured by your organization. Did you make health insurance available through any of these methods in 2011?)

(1) Yes

(2) No

>INSAVAIL_PROBE<

We include any coverage provided through a union, insurance carrier, professional association, or coverage self-insured by your organization. Did your organization make health insurance available through any of these methods in 2011?

(1) Yes

(2) No

>REFCONVERT<

This very important study is of national concern since it will have an impact on each and every one of our lives. It is very important that we have your cooperation to ensure the validity and accuracy of the data. Please be assured that all of your responses will be kept strictly confidential. May we please continue?

(1) Yes

(2) No

>MAYWEMAIL<

May I have the name of the contact person and mailing address where we can send the questionnaire?

(1) Yes

(2) No

>HOWMANYPLANS<

How many different health insurance plan choices did your organization make available or contribute to for its ACTIVE employees at your (fill address) location during the 2011 plan year?

READ IF NECESSARY: We only count comprehensive plans which cover hospital and/or physician coverage.

Single, employee-plus-one, and family coverage providing the same level of benefits are considered one plan. High and standard options under the same plan are considered 2 plans. An HMO and a conventional plan are considered 2 plans.

Number of Plans:

>STATEREPORT< (Govs)

Is there someone located at your government unit who would be able to provide information about the state sponsored health insurance plan(s) such as the type of provider arrangement, premiums, deductibles and enrollments?

(1) Yes

(2) No

>ZEROPLANPROBE<

The number of health plans should include any variety of options offered by a health insurance carrier which cover hospital stays and/or physician care. These options may cover differing levels of benefits.

Only comprehensive plans should be included.

Employers do not need to contribute to the plan premium in order for it to be counted.

Would you like to change your answer from the zero plans reported?

(1) Yes

(2) No

>LOCATIONEMP<

For this study, we define an "employee" as any worker for whom your organization withheld taxes including owners, part-time, and seasonal employees. We do not include former employees, leased or contract workers, or retirees.

Approximately, how many employees were on your organization's payroll at the location I mentioned earlier for a typical pay period in 2011?

Note: Do not attempt a new contact if this is the only item the respondent cannot answer.

Number of Employees:

>EMPZERO<

Please keep in mind that the period of reference for this study is a typical pay period in 2011. Include anyone for whom taxes were withheld. Include the owner as an employee if the owner works the majority of the time at this location. We also include all full- or part-time, temporary and seasonal employees as well as members of any union who are employed by your organization.

Would you like to change your answer from the zero employees reported?

(1) Yes

(2) No

>CP_NAME<, >CP_TITLE<, >CP_PHONE<, >CP_EXTN<

READ IF NECESSARY: The questionnaire contains items about the health insurance provider options, premiums, and enrollment as well as some employee characteristics and fringe benefits.

We will be mailing a questionnaire for this study to obtain information about the health insurance plans offered, such as health care provider options, premiums, and enrollment as well as other characteristics of your business such as fringe benefits and employee characteristics.

READ IF NECESSARY:

Are you the correct person to receive this questionnaire?

OR

May I have the name, title and phone number of the Benefits Manager or other person to whom the questionnaire should be addressed?

Contact Person Name:

Contact Person Title:

Contact Person Phone:

Contact Person Extension:

>CPMAIL_MNAME1<, >CPMAIL_MNAME2<, >CPMAIL_MSTREET1<, >CPMAIL_MSTREET2<, >CPMAIL_PLACE<, >CPMAIL_STATE<, >CPMAIL_ZIP5<, >CPMAIL_ZIP4<

READ IF NECESSARY:

What is your mailing address?

Mail CoName1:

Mail CoName2:

Mail Street1:

Mail Street2:

Mail City: Mail State: Mail Zip:

>FC_COUNTRY<

Enter the foreign country.

Country:

>FC_POSTALCODE<

Enter the foreign postal code.

Postal Code:

>PLANNAMES<

We would like to send labeled questionnaires requesting detailed information on your organization's health insurance plans.

Please provide me with the names of the [fill number of plans] health insurance plans your organization made available to its active employees in 2011 in order of enrollment, naming the plan with the largest enrollment of active employees first.

Press F10 if New Contact Needed.

If there is a union plan, but the respondent is unable to provide the name of the plan, enter “Union Plan” to hold the place for the union plan data collection.

Enter 999 if No More Plans can be named.

HEALTH PLAN NAME:

>SPELLING_REVIEW<

Review the list of plan names. Do you need to make any changes?

(List of plan names)

(1) No Changes Needed

(2) Change the number of plans

(3) Add, Edit, Delete plan names

>CHANGENUMPLANS<

Current number of plans: Number

We only count comprehensive plans which cover hospital and/or physician coverage.

Single, employee-plus-one, and family coverage providing the same level of benefits are considered one plan.

High and standard options under the same plan are considered 2 plans.

An HMO and a conventional plan are considered 2 plans.

Enter the New number of Plans:

>SPELLING_CHANGE<

To insert a row before the current row, Select ‘1’ in the first column. To delete the current row, select ‘2’ in the first column.

To edit a plan name, use the arrow keys to move to the plan you would like to edit.

When you are finished making changes, enter through the last plan name field with ‘999’.

(List of plans)

>NOINSAVAIL<

In order to make our study representative, we need to ask a few more questions of those establishments which did not make insurance available in 2011.

READ IF NECESSARY:

These questions include: some general questions about the classification of employees, the types of employees, and the fringe benefits offered.

>NOINSLAST5YEARS<

Did your organization offer any health insurance as a benefit to its employees at the location I mentioned earlier between January 1, 2006 and December 31, 2010?

READ IF NECESSARY:

(fill address)

(1) Yes

(2) No

>LASTYEARINSOFFERED<

What was the last year your organization offered health insurance coverage to its employees?

Year

>MORETHAN1LOCATION<

Does your organization have more than one location?

(1) Yes

(2) No

>TOTALEMPALL<

For this study, we define an "employee" as any worker for whom your organization withheld taxes, including owners, part-time, and seasonal employees. We do not include former employees, leased or contract workers, or retirees.

Approximately how many total employees did your organization have at ALL locations for a TYPICAL pay period in 2011?

Number of Employees:

>LOCATIONEMP<

For this study, we define an "employee" as any worker for whom your organization withheld taxes, including owners, part-time, and seasonal employees. We do not include former employees, leased or contract workers, or retirees.

Approximately, how many employees were on your organization's payroll at the location I mentioned earlier for a typical pay period in 2011?

Number of Employees:

>EMPZERO<

Please keep in mind that the period of reference for this study is a typical pay period in 2011. Include anyone for whom taxes were withheld. Include the owner as an employee if the owner works the majority of the time at this location. We also include all full- or part-time, temporary and seasonal employees as well as members of any union who are employed by your organization.

Would you like to change your answer from the zero employees reported?

(1) Yes

(2) No

>EMPCLASS_INTRO<

The next set of questions will ask about different employee classifications. Estimates or percentages are acceptable where numeric replies are needed.

>PARTTIMEGOV< (Govs)

Did your government unit have any part-time employees in 2011?

(1) Yes

(2) No

>DEMOCHARS_PARTTIME_NUM<

How many employees at this location were part-time?

Read if necessary: Can you provide a percentage value?

Number of Employees:

>DEMOCHARS_WOMEN_NUM<

How many employees at this location were women?

Read if necessary: Can you provide a percentage value?

Number of Employees:

>DEMOCHARS_50PLUS_NUM<

How many employees at this location were 50 years old or older?

Read if necessary: Can you provide a percentage value?

Number of Employees:

>DEMOCHARS_UNION_NUM<

How many employees at this location were union members?

Read if necessary: Can you provide a percentage value?

Number of Employees:

>WAGES_UNDER_NUM<

For a typical pay period in 2011, how many employees made:

Less than $11.50 per hour?

Read if necessary: This is about $24,000 a year or less.

Read if necessary: Can you provide a percentage value?

Number of Employees:

>WAGES_BTWN_NUM<

For a typical pay period in 2011, how many employees made:

Between $11.50 and $26.50 per hour?

Read if necessary: This is between $24,000 and $55,000 a year.

Read if necessary: Can you provide a percentage value?

Number of Employees:

>WAGES_OVER_NUM<

For a typical pay period in 2011, how many employees made:

More than $26.50 per hour?

Read if necessary: This is about $55,000 a year or more.

Read if necessary: Can you provide a percentage value?

Number of Employees:

>FRINGEBENEFITS_VAC<, >FRINGEBENEFITS_SICK<, >FRINGEBENEFITS_LIFE<, >FRINGEBENEFITS_DISABLE<, >FRINGEBENEFITS_RETIRE<

I am going to read a list of 5 types of benefits. As I read each one, please indicate whether or not your organization offered that benefit to its employees in 2011.

Paid Vacation?

Paid Sick Leave?

Life Insurance?

Disability Insurance?

Retirement or Pension Plans?

(1) Yes

(2) No

>TAXADBENEFITS_FSA<, >TAXADBENEFITS_FBP<

Did your organization offer either of the following tax advantaged benefits to its employees at this location in 2011?

Flexible Spending Account for healthcare?

Flexible Benefits Plans also known as Full Cafeteria Plans?

(1) Yes

(2) No