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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)
§>"+-¤
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)
§>"+5¤
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
§>"+G¤
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
29011046
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
§>"+O¤
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
29011053
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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.
29011061
§>"+^¤
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?
29011079
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)
§>"+p¤
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)
§>"+x¤
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)
§>"+¢¤
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
§>",$¤
*** PLEASE NOTE ***
OMB No. 0935-0110: Approval Expires 01/31/2013
2011 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE
COST STUDY
Government Questionnaire
(Please correct any errors in name, address, and ZIP Code.
Enter number and street, if not shown.)
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
RETURN TO
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001 OR
Fax to 1–800–447–4613
PLEASE RETURN ENTIRE PACKAGE WITHIN
PLEASE DO NOT REMOVE THIS COVER SHEET
FORM MEPS-11(F) (02-24-2011)
§>$++¤
29031010
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address: http://respond.census.gov/meps11
Your Survey Key to access the Internet form is:
2
INSTRUCTIONS
1. Please report for the government unit identified on the cover sheet.
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 1-888-273-3878.
Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, to complete the basic questionnaire. If you offered more than one plan, we
expect it will take an additional 10 minutes per plan, on average. 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-11(F) (02-24-2011)
§>$+=¤
29031028
We are conducting this study under the authority of Section 913 of the Public Health Service Act
(Title 42, United States Code (U.S.C.), Section 299b-2). Sections 924c and 308d of that Act (42
U.S.C. Section 299c-3(c) and 42 U.S.C. Section 242m, respectively) ensure that the information you
report will be released only to authorized staff of the Census Bureau, the Agency for Healthcare
Research and Quality, and their authorized researchers and contractors.
3
Section A - NUMBER OF PLANS
Please respond for the government unit identified on the cover sheet unless otherwise specified.
Respond for ACTIVE employees only.
1a. Did your government unit make available or
contribute to the cost of any health insurance
plans for its ACTIVE employees in 2011?
001
For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.
b. How many different health insurance plan
choices did your government unit make
available or contribute to for its ACTIVE
employees during the 2011 plan year?
1
Yes - Continue with Question 1b
2
No - SKIP to MEPS-11(R), Section C,
Question 1
003
Number of Health Plans offered
Do not count single service plans (optional plans) such as
dental or vision.
Plans offered by the same insurance company which offer:
• Single, employee-plus-one, and family coverage
providing the same level of benefits count as ONE
plan.
• High and standard options count as TWO plans.
• An HMO and a conventional plan from the same
insurance company count as TWO plans.
Remarks
29031036
§>$+E¤
500
Continue with Section B on MEPS-11(S)
FORM MEPS-11(F) (02-24-2011)
OMB No. 0935-0110: Approval Expires 01/31/2013
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
government unit provide health insurance
coverage to any person who retired from your
government unit in 2011 OR BEFORE, or to any
of their survivors?
|
2. In a typical month, how many retirees were
enrolled in health insurance through your
government unit?
UNDER 65 YEARS OF AGE
Exclude any retirees that have coverage through PHSA
(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
Question 2, under 65 years of age?
b. In a typical month, how many retirees under
65 years of age were enrolled in health
insurance through your government unit?
c. What percentage of those retirees were
ENROLLED in SINGLE coverage?
d. For a typical plan in 2011, how much did the
GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with SINGLE coverage?
e. For this same plan, what was the TOTAL
29051018
monthly premium for this typical retiree with
SINGLE coverage?
f. For a typical plan in 2011, how much did the
GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with FAMILY coverage?
For retirees, if premium varied by family size, report for a
family of two.
g. For this same plan, what was the TOTAL
monthly 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?
FORM MEPS-11(R) (03-09-2011)
1
Yes - This government unit - Continue with
Question 2
Yes - Another government unit
4
|
|
672
|
Enter name of other government unit
Continue with Question 2 if information is
available. Otherwise SKIP to Page 3, Section D.
|
|
|
If PHSA (COBRA) was the only coverage offered mark
"No".
551
|
|
|
|
|
|
|
|
||
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|
|
|
|
|
|
|
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|
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|
|
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|
|
|
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|
|
|
|
551
2
No
3
Don’t know
}
SKIP to Page 3, Section D
513
Number of retirees enrolled
628
1
Yes - Continue with Question 3b
2
No - SKIP to Page 2, Question 4a
572
Number of retirees under 65
enrolled in health insurance
573
% Retirees under 65 enrolled
in single coverage
Government unit
574
$
.00 contribution for
,
single premium
575
$
576
.00 Total single
,
premium
Government unit
$
.00 contribution for
,
family premium
577
$
724
1
.00 Total family
,
Yes
premium
2
No
3
Don’t know
Continue with Page 2, Question 4a
§>&+3¤
1. Does your government unit or some other
|
➤
Exclude any retirees that have coverage through PHSA
(COBRA) or state continuation-of-benefits laws. See the
definition sheet included with this package for an
explanation of these terms.
2
Section C - RETIREE HEALTH COVERAGE CHARACTERISTICS - Continued
AGE 65 YEARS OR OVER
Exclude any retirees that have coverage through
PHSA (COBRA) or state continuation-of-benefits laws.
629
4a. Were any of the enrolled retirees, reported in
Question 2, 65 years of age or over?
b. In a typical month, how many retirees 65 years
of age or over were enrolled in health insurance
through your government unit?
c. What percentage of these retirees were
1
Yes - Continue with Question 4b
2
No - SKIP to Question 5a
Number of retirees
65 years or over enrolled
in health insurance
578
Retirees 65 years
579
% or over enrolled
ENROLLED in SINGLE coverage?
d. For a typical plan in 2011, how much did the
in single coverage
Government unit
580
$
GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with SINGLE coverage?
e. For this same plan, what was the TOTAL
581
f. For a typical plan in 2011, how much did the
583
725
outpatient prescription drugs for retirees
65 years of age or over?
.00 Total single
,
$
premium
.00 contribution for
,
$
monthly premium for this typical retiree with
FAMILY coverage?
h. Did a typical plan provide coverage for
single premium
Government unit
582
GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with FAMILY coverage?
For retirees, if premium varied by family size, report for
a family of two.
g. For this same plan, what was the TOTAL
,
$
monthly premium for this typical retiree with
SINGLE coverage?
.00 contribution for
family premium
.00 Total family
,
premium
1
Yes
No
1
Yes - Continue with Question 5b
2
No
2
3
Don’t know
NEW RETIREES
630
For Questions 5a through 5c, NEW RETIREES refers
only to persons who retired from your government unit
in 2011.
5a. Did your government unit offer health insurance
to any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
29051026
eligible for health insurance?
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
SKIP to Page 3, Section D
631
eligible for health insurance?
c. Were NEW RETIREES 65 years of age or over
3
}
632
Continue with Page 3, Section D
FORM MEPS-11(R) (03-09-2011)
§>&+;¤
Exclude any retirees that have coverage through PHSA
(COBRA) or state continuation-of-benefits laws.
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 2011 at a premium
SEPARATE from the comprehensive health
plan premium?
192
Dental
193
Vision
Report single service insurance plans only.
Do not include single services covered under a
comprehensive health plan.
Long-term care insurance helps to cover the cost of
institutional and home care required by the chronically ill
or disabled.
Mark (X) all that apply.
194
Prescription drugs
195
Long-term care
562
No optional coverage - SKIP to Question 2a
b. What was the total amount paid for optional
720
$
coverage for all ACTIVE employees at THIS
GOVERNMENT UNIT during a typical month in
2011?
2a. For 2011, did your government unit impose a
.00
,
,
Monthly optional coverage cost
197
waiting period before new employees could be
covered by health insurance?
b. For 2011, what was the typical waiting period?
Continue with Question 1b
1
Yes - Continue with Question 2b
2
No - SKIP to Section E
1
Less than 2 weeks
198
Mark (X) only one.
2
5
2 weeks to less
than 1 month
Until the first day
of the next month
3
1-3 months
4
More than 3 months
Section E - EMPLOYMENT CHARACTERISTICS
b. How many of these ACTIVE employees were
201
Eligible employees
202
ENROLLED in ANY health plan through your
government unit?
2a. For the same typical pay period in 2011, did
Enrolled employees
563
your government unit have any part-time
employees?
1
Yes - Continue with Question 2b
2
No
3
b. How many of these part-time employees were
Don’t know
29051034
Eligible part-time employees
205
ENROLLED in ANY health plan through your
government unit?
3.
4.
Enrolled part-time employees
Did your government unit offer health insurance
to its temporary or seasonal employees in
2011?
Mark (X) only one.
564
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?
626
FORM MEPS-11(R) (03-09-2011)
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
}
721
1
Yes
4
No temporary or
seasonal employees
2
No
3
Don’t know
Minimum hours worked per
week to be eligible
No minimum number of hours required
Continue with Page 4, Section F
§>&+C¤
1a.
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include part-time, temporary, and seasonal employees.
Exclude leased or contract workers and retirees.
How many ACTIVE employees were ELIGIBLE
for at least one health plan through your
government unit for a typical pay period in
2011?
4
|
Section F - FRINGE BENEFITS
CHARACTERISTICS
|
1. Did your government unit offer the following
fringe benefits to its employees in 2011?
050
Paid vacation. . . . . . . . . . . . . . . .
051
Paid sick leave. . . . . . . . . . . . . . .
052
Life insurance . . . . . . . . . . . . . . .
053
Disability insurance. . . . . . . . . . . .
054
Retirement/pension plans . . . . . . .
Yes
(1)
Don’t
No know
(2)
(3)
Yes
(1)
Don’t
No know
(2)
(3)
2. Did your government unit offer any of these
tax-advantaged benefits to its employees in
2011?
See the definition sheet included with this package for
an explanation of these benefits.
627
Employee contributions to health
insurance made on a pre-tax basis
These plans are also known as Section 125 Cafeteria
Plans.
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
Section G - EMPLOYEE CHARACTERISTICS
Provide information for a typical pay period
in 2011.
Estimates are acceptable.
The following workforce characteristics are used to
group similar government units together for analytical
purposes.
If none, enter "0".
016
%
employees at this government unit were
women?
2. Approximately what percentage of the
017
employees at this government unit were 50
years old or older?
3. Approximately what percentage of the
%
Employees 50 years old or older
018
%
employees at this government unit were
union members?
29051042
Women employees
Union members
4. For the employees at this government unit in
2011, approximately what percentage
earned 022
Less than $11.50 per hour? . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
% Earned less than $11.50 per hour
023
Between $11.50 and $26.50 per hour?. . . . . . .
Approximately $24,000 to $55,000 a year
Earned between $11.50 and
% $26.50 per hour
024
More than $26.50 per hour?. . . . . . . . . . . . . . . .
Approximately $55,000 a year or more
% Earned more than $26.50 per hour
Continue with Page 5, Section H
FORM MEPS-11(R) (03-09-2011)
§>&+K¤
1. Approximately what percentage of the
5
Section H - PERSON COMPLETING THIS QUESTIONNAIRE
212 Name (Please print)
213 Title (Please print)
214 Date (Month/Day/Year)
Signature
220 Extension 216 Fax
215 Telephone number
–
–
29051059
§>&+\¤
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-11(R) (03-09-2011)
OMB No. 0935-0110: Approval Expires 01/31/2013
2011 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE
COST STUDY
Government Questionnaire
(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/meps11
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-11C(F) (03-25-2011)
§>’+2¤
29061017
Your Survey Key to access the Internet form is:
2
INSTRUCTIONS
1. Please report for the government unit identified on the cover
sheet.
2. 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 copy of this completed form for your records.
7. In addition to the completed questionnaire, please include a copy
of each of your health insurance plan brochures describing
the benefits offered, or a copy of the benefits sheet summarizing the
benefits offered by each of your plans.
29061025
We are conducting this study under the authority of Section 913 of the Public Health
Service Act (Title 42, United States Code (U.S.C.), Section 299b-2). Sections 924c and 308d
of that Act (42 U.S.C. Section 299c-3(c) and 42 U.S.C. Section 242m, respectively) ensure
that the information you report will be released only to authorized staff of the U.S. Census
Bureau, the Agency for Healthcare Research and Quality, and their authorized researchers
and contractors.
Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, to complete the basic questionnaire. If you offered more than one plan, we expect
it will take an additional 10 minutes per plan, on average. 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-11C(F) (03-25-2011)
§>’+:¤
8. If you have any questions or need assistance in completing the
questionnaire, please call 1-888-206-5068.
3
Section A – NUMBER OF PLANS
Please respond for the government unit identified on the cover sheet.
Respond for ACTIVE employees only.
1a. Did your government unit make available or
001
contribute to the cost of any health insurance
plans for its ACTIVE employees in 2011?
1
Yes – Continue with Question 1b
2
No – Complete contact information
below then SKIP to
MEPS-11C(R), Section C
For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.
b. How many different health insurance plan
choices did your government unit make
available or contribute to for its ACTIVE
employees during the 2011 plan year?
003
Number of health plans offered
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.
c. Are health benefits brochures for those plans
671
available on a website?
Please provide, in remarks section below, the general user
information to access brochures, if needed and available.
Yes – Please provide website address below
2
No – Complete contact information
below then CONTINUE with
MEPS-11C(S), Section B
Remarks
29061033
CONTACT INFORMATION – PERSON COMPLETING THIS QUESTIONNAIRE
212 Name (Please print)
213 Title (Please print)
Signature
217 Email (Please print)
220 Extension 216 Fax
215 Telephone number
–
–
670 Brochure Website address
214 Date (Month/Day/Year)
http: //
FORM MEPS-11C(F)
(03-25-2011)
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
§>’+B¤
500
1
OMB No. 0935-0110: Approval Expires 01/31/2013
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 2011 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
29081015
§>)+0¤
Continue with Question 3a
FORM MEPS-11C(R) (02-28-2011)
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 2011, 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 2011, how much did
629
572
TOTAL number of retirees, by age
category, enrolled in health insurance
through your government unit in 2011?
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
29081023
NEW RETIREES
For questions 4a through 4c, NEW RETIREES
refers to persons who retired from your government
unit in 2011.
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) (02-28-2011)
632
}
SKIP to Section D
§>)+8¤
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 2011 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
2011?
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 2011?
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 2011?
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 2011?
Enrolled part-time employees
564
29081031
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
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 Section F
FORM MEPS-11C(R) (02-28-2011)
§>)+@¤
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 2011?
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
2011?
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
2011.
Estimates are acceptable.
The following workforce characteristics are used to group
similar government units together for analytical purposes.
If none, enter "0".
016
Approximately what percentage of the employees
at this government unit were women?
2.
Approximately what percentage of the employees
at this government unit were 50 years old or
older?
017
Approximately what percentage of the employees
at this government unit were union members?
018
3.
29081049
4.
For the employees at this government unit 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
%
%
%
Women employees
Employees 50 years old or older
Union members
022
%
Earned less than $11.50 per hour
023
%
Earned between $11.50 and $26.50
per hour
024
%
Earned more than $26.50 per hour
Thank you for your cooperation in completing this survey.
The U.S. Census Bureau appreciates your assistance.
FORM MEPS-11C(R) (02-28-2011)
§>)+R¤
1.
OMB No. 0935-0110: Approval Expires 1/31/2013
2011 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE
COST STUDY
Company Questionnaire
(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-15 (03-11-2011)
§>*+/¤
29091014
Your Survey Key to access the Internet form is:
2
INSTRUCTIONS
1. Please report for the company identified on the cover sheet, unless
otherwise specified.
A COMPANY, for the purposes of this study, is a business with its
own management and legal structure. A company represents the
entire organization, including the headquarters and all divisions,
subsidiaries, and branches within the organizational family.
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 1-888-206-8023 or visit
http://www.census.gov/econhelp/meps/cmu/index.html.
Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, per company, to complete the basic questionnaire. Companies 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-15 (03-11-2011)
§>*+7¤
29091022
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
1a. Are you reporting for your entire company?
b. If you are reporting for a portion of your total
535
1
Yes – SKIP to Question 2a
2
No – Continue with Question 1b
528
company, approximately what percentage of
the company’s total 2011 employment are you
reporting?
%
Company employment
Briefly explain
529
Respond for ACTIVE employees only.
2a. Did your company make available or contribute
001
to the cost of any health insurance plans for its
ACTIVE employees in 2011?
1
Yes – Continue with Question 2b
2
No – SKIP to Page 4, Section B
For this survey, a health insurance plan is hospital and/or
physician coverage made available to employees.
b. How many different health insurance plan
choices did your company make available or
contribute to for its ACTIVE employees at a
TYPICAL location during the 2011 plan year?
003
Health insurance plan choices at a
typical location
Report for a single establishment within your company
which you think offered a "TYPICAL" array of health
insurance plans.
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.
29091030
• An HMO and a conventional plan from the same
insurance company count as two plans.
FORM MEPS-15 (03-11-2011)
Continue with Page 4, Section B
§>*+?¤
• High and standard options count as two plans.
4
Section B – 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.
1a. What was the total number of employees your
034
company had at ALL locations for a TYPICAL pay
period in 2011?
Employees at all locations
If your company did not offer health
insurance in 2011, SKIP to Question 2a
b. How many of these employees were ELIGIBLE
201
for at least one health plan through your
company?
c. How many of these employees were ENROLLED
Eligible employees
202
in ANY health plan through your company?
Enrolled employees
2a. For the same TYPICAL pay period in 2011, how
203
many of the employees reported in 1a worked
part-time?
Part-time employees
If your company did not offer health
insurance in 2011, SKIP to Page 5, Question 6a
204
ELIGIBLE for at least one health plan through
your company?
c. How many of these part-time employees were
Eligible part-time employees
205
ENROLLED in ANY health plan through your
company?
3. Did your company offer health insurance to its
Enrolled part-time employees
564
temporary or seasonal employees in 2011?
1
Yes
Mark (X) only one.
2
No
4
No temporary or seasonal employees
3
Don’t know
4. If your company offered health insurance, what
29091048
is the minimum number of hours per week that
an employee must work in order to be eligible
for health insurance?
FORM MEPS-15 (03-11-2011)
626
721
Minimum hours worked per
week to be eligible
No minimum number of hours required
§>*+Q¤
b. How many of these part-time employees were
5
Section B – EMPLOYMENT CHARACTERISTICS - Continued
5.
Of the active employees enrolled in a health
insurance plan your company offered in 2011,
what percentage were ENROLLED in each of the
following provider arrangements?
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 incentive to use a particular group of
providers.
Active enrollment by type –
518
% Exclusive providers (Examples:
Most HMO, IPA, and EPO-type plans)
519
% Any providers (Examples: Most
fee-for-service plans)
520
Mixture of preferred and any
% providers (Examples: Most PPO
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.
and POS-type plans)
Provide information for a TYPICAL pay period in 2011.
Estimates are acceptable.
The following workforce characteristics are used to group
similar companies together for analytical purposes.
If none, enter "0".
6a. Approximately what percentage of the total
016
employees at your company were women?
b. Approximately what percentage of the total
%
017
employees at your company were 50 years old
or older?
c. Approximately what percentage of the total
Women employees
%
Employees 50 years old or older
018
employees at your company were union
members?
%
Union members
d. For the employees at your company in 2011,
approximately what percentage earned –
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
023
between $11.50 and $26.50
% Earned
per hour
024
% Earned more than $26.50 per hour
29091055
Continue with Page 6, Section C
FORM MEPS-15 (03-11-2011)
§>*+X¤
Less than $11.50 per hour? . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
6
Section C – BUSINESS CHARACTERISTICS
1a. Did your company offer the following fringe
benefits to its employees in 2011?
Yes
No
Don’t
know
(1)
(2)
(3)
Yes
No
Don’t
know
(1)
(2)
(3)
Mark (X) all that apply.
050
Paid vacation . . . . . . . . . . . . . . . . .
051
Paid sick leave . . . . . . . . . . . . . . . .
052
Life insurance . . . . . . . . . . . . . . . . .
053
Disability insurance . . . . . . . . . . . . .
054
Retirement/pension plans . . . . . . . . .
b. Did your company offer any of the following
tax-advantaged benefits to its employees in
2011?
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
See the definition sheet included with this package for an
explanation of these benefits.
These benefits are also known as Section 125 Cafeteria
Plans.
2.
How many establishments does your company
operate nationally?
530
Establishments
29091063
§>*+‘¤
Continue with Page 7, Section D
FORM MEPS-15 (03-11-2011)
7
Section D – RETIREE HEALTH COVERAGE CHARACTERISTICS
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 company 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
If COBRA was the only coverage offered, mark "No."
Don’t know
3
2.
In a typical month, how many retirees were
enrolled in health insurance through your
company?
}
SKIP to Page 9, Section E
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.
628
Question 2, under 65 years of age?
b. In a typical month, how many retirees under 65
1
Yes – Continue with Question 3b
2
No – SKIP to Page 8, Question 4a
572
years of age were enrolled in health insurance
through your company at all of its locations in
2011?
c. What percentage of these retirees were
Number of retirees under 65
enrolled in health insurance
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?
29091071
single premium
575
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2011, how much did the
.00 Employer contribution for
,
$
.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 on Page 8, Question 4a
FORM MEPS-15 (03-11-2011)
§>*+h¤
3a. Were any of the enrolled retirees, reported in
8
Section D – 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 company in 2011?
c. What percentage of these retirees were
579
% Retirees 65 or over enrolled in single
ENROLLED in SINGLE coverage?
d. For a typical plan in 2011, how much did the
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
$
single premium
581
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2011, how much did the
.00 Employer contribution for
,
$
.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 outpatient
$
725
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 company in 2011.
630
Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.
5a. Did your company offer health insurance to any
29091089
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
eligible for health insurance?
632
}
SKIP to Page 9, Section E
Continue with Page 9, Section E
FORM MEPS-15 (03-11-2011)
§>*+z¤
NEW RETIREES
9
Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS
192
Dental
193
Vision
Do not include single services covered under a
comprehensive health plan.
194
Prescription drugs
Long-term care insurance helps cover the cost of
institutional and home care required by the chronically ill
or disabled.
195
Long-term care
Mark (X) all that apply.
562
No optional coverage – SKIP to Question 2a
b. What was the total amount paid for optional
$
197
period before new employees could be covered
by health insurance?
b. For 2011, what was the TYPICAL waiting period?
198
Mark (X) only one.
4.
Did your company 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 company provide any financial
compensation or incentives to employees if
they did not elect to receive health insurance
coverage?
,
,
.00
Monthly optional coverage cost
Include both employer and employee contributions.
2a. For 2011, did your company impose a waiting
Continue with Question 1b
720
coverage for all ACTIVE employees during a
TYPICAL MONTH at your company in 2011?
3.
}
if any, did your company offer to its ACTIVE
employees in 2011 at a premium SEPARATE
from the comprehensive health plan premium?
Report single service insurance plans only.
722
723
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
29091097
Continue with Page 10, Section F
FORM MEPS-15 (03-11-2011)
§>*+¿¤
1a. Which of the listed optional coverage services,
10
500 Remarks
Section F – PERSON COMPLETING THIS QUESTIONNAIRE
*** PLEASE NOTE ***
29091105
If your company DID NOT offer health insurance, please complete
Section F and SKIP to the attached MEPS-15(E), Establishment
Worksheet.
212 Name (Please print)
213 Title (Please print)
214 Date (Month/Day/Year)
Signature
215 Telephone number
220 Extension 216 Fax
–
FORM MEPS-15 (03-11-2011)
–
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
§>*,&¤
If your company offered health insurance, please complete Section F
and an attached MEPS-15(S), Plan Information Questionnaire, for each
plan offered up to four.
OMB No. 0935-0110: Approval Expires 01/31/2013
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
Location Worksheet
Start
here
A FEW IMPORTANT INSTRUCTIONS
• In this section, please report for the small sample of locations chosen to represent your company.
• In Column (c), mark "Yes" if the location listed in Column (b) is included in the corporate figures reported on
the MEPS-15. Mark "No" if the location is not included in the corporate figures reported on the MEPS-15.
• In Column (d), enter the number of employees at the location listed in Column (b) for a typical pay period in
2011. Estimates are acceptable.
• In Columns (e), (f), and (g), please check the types of hospital and/or physician insurance plans which your
company offered at the location specified in Column (b). See the MEPS-20D, definition sheet, included in this
package for detailed explanations of the different types of plans.
Location
Identification Number
(a)
Name of location
Have you
answered for
this location
on the
MEPS-15?
(b)
(c)
(d)
524
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
524
524
524
524
29111010
524
524
524
524
FORM MEPS-15(E) (01-06-2011)
Number
of
employee(s)
Types of provider
arrangements offered
(Mark (X) all that apply)
HMO/ Conventional
EPO
Indemnity
(e)
(f)
PPO/
POS
(g)
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
§>,++¤
CENSUS USE ONLY
Location
Identification Number
(a)
Name of location
Have you
answered for
this location
on the
MEPS-15?
(b)
(c)
(d)
524
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
1
Yes
2
No
524
524
524
524
524
524
524
524
524
524
29110020
524
524
524
524
FORM MEPS-15(E) (01-06-2011)
Number
of
employee(s)
Types of provider
arrangements offered
(Mark (X) all that apply)
HMO/ Conventional
Indemnity
EPO
(e)
(f)
PPO/
POS
(g)
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
200
521
522
523
§>,!5¤
CENSUS USE ONLY
| File Type | application/pdf |
| File Title | meps10p01_11.g |
| File Modified | 2011-07-15 |
| File Created | 2011-07-15 |