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pdfOMB 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
2011 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2011 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 2011, 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.
29021011
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) (03-09-2011)
§>#+,¤
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.
713
1
Yes - Used a third party administrator
2
No - Self-administered the plan
1
Yes
2
No
6a. Did your organization employ a third party
administrator (TPA) for this self-insured plan?
b. Did your organization purchase stop-loss
107
coverage for this plan?
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
7a. How many ACTIVE employees at this location
125
Active employees enrolled
in plan
129
Active employees enrolled
in single coverage
571
Active employees enrolled
in employee-plus-one
coverage
705
Active employees enrolled
in family coverage
were ENROLLED in this plan during a typical
pay period in 2011?
Include full-time, part-time, temporary and seasonal
employees.
b. How many of these ACTIVE employees were
ENROLLED in SINGLE coverage during a
typical pay period in 2011?
29021029
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 2011?
Include enrollment for both employee-plus-spouse and
employee-plus-child(ren) coverage.
d. How many ACTIVE employees were ENROLLED
in FAMILY (not single or employee-plus-one)
coverage during a typical pay period in 2011?
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 2011?
126
Former employees enrolled
in plan, excluding retirees
Continue with Page 3, Question 9a
FORM MEPS-10(S) (03-09-2011)
§>#+>¤
Exclude former employees, leased or contract workers
and retirees.
3
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 2011.
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
Total single
.00 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?
29021037
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) (03-09-2011)
§>#+F¤
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.
4
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
Total family
$
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 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
29021045
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) (03-09-2011)
151
1
Yes - Continue with Question 13b
2
No - SKIP to Page 5, Question 16a
§>#+N¤
OR
5
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 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 2011?
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?
29021052
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) (03-09-2011)
§>#+U¤
PAYMENTS
6
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?
29021060
$
.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) (03-09-2011)
§>#+]¤
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 2011?
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 ***
29021078
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) (03-09-2011)
§>#+o¤
If your organization offered only one health insurance plan,
you have completed your response to this survey.
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
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health
insurance plans offered in 2011 AT THIS GOVERNMENT UNIT. Please use photocopies
of this MEPS-11(S) form if sufficient copies were not included in this reporting package.
Section B - GENERAL PLAN INFORMATION
Begin with the plan having the largest enrollment and proceed through to the plan with the smallest enrollment of
ACTIVE employees.
Please photocopy this MEPS-11(S) questionnaire if additional forms are needed.
1. For 2011, 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
• Option A
• Aetna HMO
2. Which type of health care provider arrangement
103 1
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.
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
29041019
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.
3. Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order to
be referred to a specialist?
104
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-11(S) (03-09-2011)
§>%+4¤
was available through this plan?
2
GENERAL PLAN INFORMATION
- Continued
|
|
| 105
1
Purchased - SKIP to Question 7a
underwriter or was it self-insured?
|
|
Purchased from an insurance underwriter 2
Self-insured - Continue with Question 6a
|
(Fully-insured) Coverage is purchased from an insurance
|
company or other underwriter who assumes the risk for
|
the enrollees’ medical expenses.
3
Don’t know - SKIP to Question 7a
|
Self-insured - Your government unit 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.
| 713
1
Yes - Used a third party administrator
|
Did your government unit employ a third party
|
administrator (TPA) for this self-insured plan?
|
2
No - Self-administered the plan
|
| 107
Did your government unit purchase stop-loss
1
Yes
|
coverage for this plan?
|
|
2
No
|
|
ACTIVE ENROLLMENT
|
|
Estimates are acceptable for all enrollment figures.
|
How many ACTIVE employees were
Active employees enrolled
| 125
ENROLLED in this plan at this government
in plan at this government unit
|
unit during a typical pay period in 2011?
|
|
Include full-time, part-time, temporary and seasonal
employees.
|
|
Exclude retirees, former employees, leased or contract
|
workers.
|
| 129
How many of these ACTIVE employees were
Active employees enrolled
ENROLLED in SINGLE coverage during a typical |
in single coverage
|
pay period in 2011?
|
|
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 government unit offered
571
Active employees enrolled
|
EMPLOYEE-PLUS-ONE coverage, how many
in employee-plus-one
|
ACTIVE employees were ENROLLED during a
coverage
|
typical pay period in 2011?
|
Include enrollment for both employee-plus-spouse and
|
employee-plus-child(ren) coverage.
|
| 705
How many of these ACTIVE employees were
Active employees enrolled
|
ENROLLED in FAMILY (not single or
in family coverage
|
employee-plus-one) coverage during a typical
|
pay period in 2011?
|
PHSA (COBRA)| ENROLLMENT
|
How many FORMER employees were ENROLLED | 126
Former employees enrolled
|
in this plan, excluding retirees, through PHSA
in plan, excluding retirees
|
(COBRA) or state continuation-of-benefits laws
|
during a typical pay period in 2011?
|
Continue with Page 3, Question 9a
|
6a.
b.
7a.
b.
29041027
c.
d.
8.
FORM MEPS-11(S) (03-09-2011)
§>%+<¤
5. Was this plan purchased from an insurance
3
PLAN PREMIUMS
Report for TYPICAL situations and enrollees.
If this was a self-insured plan, report the premium equivalent.
If premium varied, report for a TYPICAL employee.
Report government unit/employee contributions and total premium for the same period in 2011.
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 for premiums.
9a.
b.
c.
d.
e.
10a.
b.
29041035
c.
d.
e.
|
|
EMPLOYEE-PLUS-ONE COVERAGE
|
|
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.
|
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.
|
Was EMPLOYEE-PLUS-ONE coverage offered
|
under this plan?
|
|
For this plan, how much did the GOVERNMENT
|
UNIT contribute toward the plan premium of
|
one typical employee with EMPLOYEE|
PLUS-ONE coverage?
|
|
How much did this typical EMPLOYEE with
EMPLOYEE-PLUS-ONE coverage contribute
|
toward his/her own premium?
|
|
What was the TOTAL premium for this typical |
|
employee with EMPLOYEE-PLUS-ONE
|
coverage?
|
The amounts reported in questions 10b-d are
|
based on which one of the following time
|
periods?
|
Mark (X) only one.
|
|
|
FORM MEPS-11(S) (03-09-2011)
552
1
Yes - Continue with Question 9b
2
No - SKIP to Question 10a
Government unit
131
$
,
.00 contribution for
single premium
Employee
132
$
,
.00 contribution for
single premium
130
$
133
Total single
,
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
570
636
$
,
637
$
,
Government unit
contribution for
.00 employee-plus-one
premium
Employee
contribution for
.00 employee-plus-one
premium
Total
635
$
638
.00 premium
,
.00 employee-plus-one
premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Continue with Page 4, Question 11a
§>%+D¤
|
|
|
Was SINGLE coverage offered under this plan? |
|
For this plan, how much did the GOVERNMENT |
UNIT contribute toward the plan premium of
|
one typical employee with SINGLE coverage? |
|
How much did this typical EMPLOYEE with
|
SINGLE coverage contribute toward his/her
|
own premium?
|
What was the TOTAL premium for this typical |
|
employee with SINGLE coverage?
|
|
The amounts reported in questions 9b-d are
|
based on which one of the following time
|
periods?
|
Mark (X) only one.
|
SINGLE COVERAGE
4
PLAN PREMIUMS
- Continued
|
|
FAMILY COVERAGE
11a.
b.
|
|
If premium varied by family size, report for a family of four.
| 137 1
Yes - Continue with Question 11b
Was FAMILY coverage offered under this plan? |
|
2
No - SKIP to Question 12a
|
|
Government unit
For this plan, how much did the GOVERNMENT | 135
contribution for
$
.00
UNIT contribute toward the plan premium of
|
family premium
one typical employee with FAMILY coverage? |
|
Employee
How much did this typical EMPLOYEE with
| 136
contribution for
FAMILY coverage contribute toward his/her
$
.00
|
family premium
own premium?
|
|
What was the TOTAL premium for this typical | 134
Total family
employee with FAMILY coverage?
$
.00 premium
|
|
|
The amounts reported in questions 11b-d are
| 553 1
Weekly
5
Quarterly
based on which one of the following time
|
periods?
|
2
Every 2 weeks
4
Yearly
|
Mark (X) only one.
|
3
Monthly
|
|
GENERAL PREMIUM
INFORMATION
|
|
Did the PREMIUMS charged by the insurance
Age
| 138
company or carrier vary by any of these
|
characteristics?
139
Gender
|
|
Mark (X) all that apply.
141
Wage or salary level
|
|
142
Other
|
|
OR
|
Premiums did not vary
| 640
|
Did the amount an EMPLOYEE CONTRIBUTED |
Hours worked
| 641
toward his/her own coverage vary by any of
,
c.
,
d.
e.
12a.
b.
these employee characteristics?
29041043
Mark (X) all that apply.
INDIVIDUAL
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-11(S) (03-09-2011)
|
Union status
| 642
|
Wage or salary level
643
|
|
644
Occupation
|
| 706
Length of employment
|
| 645
Other
|
|
OR
|
| 646
Employee contribution did not vary
|
|
DEDUCTIBLES
|
|
151
|
1
Yes - Continue with Page 5, Question 13b
|
|
2
No - SKIP to Page 5, Question 16a
|
|
|
§>%+L¤
,
5
|
INDIVIDUAL DEDUCTIBLES
- Continued
13b. What was the annual deductible an individual
paid?
Report "in-network" deductibles (if applicable).
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 16b.
DO NOT report COPAYMENTS or individual or family
maximums here.
|
|
|
|
|
|
|
|
|
|
|
|
|
146
$
.00 Individual annual
,
deductible
OR
Separate deductibles for:
147
$
,
.00
Physician care
148
$
,
.00
Hospital care
FAMILY DEDUCTIBLES
|
| 224
1
Yes - Continue with Question 14b
|
of family members meet their individual
|
deductibles before the family deductible
2
No - SKIP to Question 14c
was met?
|
|
Family coverage not offered - SKIP to
3
|
Question 15
|
|
How many family members were required to
| 150
meet their individual deductibles before the
|
family deductible was met?
Number of family members
|
Report for a family of four.
|
|
What was the total annual deductible a
| 149
family paid?
$
.00 Total annual family
|
deductible
|
Report for a family of four.
|
HEALTH SAVINGS| ACCOUNT (HSA)
|
|
If the deductibles you reported in questions 13 | 714 1
Yes, contributed to an HSA
and 14 were $1,200 or higher for single
|
coverage and $2,400 or higher for family
2
No, did not contribute to an HSA
coverage, did your government unit contribute |
to a Health Savings Account (HSA) for the plan |
4
Don’t know
|
enrollees in 2011?
|
|
PAYMENTS
|
| 155
1
Was hospital care covered under this plan?
Yes - Continue with Question 16b
|
|
2
No - SKIP to Page 6, Question 16c
|
|
|
Copayment paid by
How much and/or what percentage of the
152
|
total bill did an enrollee pay out-of-pocket
$
.00 enrollee for hospital
admission
|
for an inpatient hospital admission after
any annual deductible was met?
|
154
|
Out-of-pocket expense - Those costs paid directly
1
Per day
|
by the enrollee.
|
2
Per stay
Some plans may have both a dollar copayment and a
|
percentage coinsurance.
AND/OR
|
Report for precertified hospital admissions (if applicable). |
153
|
% Coinsurance
Report for an admission at an "in-network"/participating
paid by enrollee
|
hospital (if applicable).
|
Do not include any physician charges incurred during
|
the hospital admission.
|
|
Continue with Page 6, Question 16c
|
14a. Did this plan require that a specific number
b.
c.
15.
16a.
b.
29041050
,
FORM MEPS-11(S) (03-09-2011)
§>%+S¤
,
6
PAYMENTS | - Continued
d. How much and/or what percentage of the total
bill did an enrollee pay out-of-pocket for an
office visit after any annual deductible was
met?
Out-of-pocket expense - Those costs paid directly
by the 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?
18. How many different pricing categories or
tiers of prescription drug coverage were
there for this plan?
19. 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.
Include all copayments, coinsurance and deductibles.
20a. What was the MAXIMUM ANNUAL 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 out-of-pocket
29041068
expense for a family of four?
21. What was the MAXIMUM amount this plan
would have paid for an enrollee in ONE
YEAR?
FORM MEPS-11(S) (03-09-2011)
218
1
Yes - Continue with Question 16d
2
No - SKIP to Question 17
156
.00 Copayment paid by enrollee
$
for office visit
AND/OR
157
% Coinsurance
paid by enrollee
673
1
Yes - Continue with Question 18
2
No
3
Don’t know
}
SKIP to Question 20a
712
Number of tiers
715
Don’t know
Lowest cost to enrollee
655
$
.00
Copayment
And/Or
677
%
Coinsurance
161
$
.00
,
OR
163
No individual maximum
162
$
.00
,
OR
222
No family maximum
160
$
,
,
.00
OR
221
No annual maximum
Continue with Page 7, Question 22
§>%+e¤
16c. Was physician care covered under this plan?
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
7
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
|
|
Arrangement (HRA) by setting up an account to | 710 1
Yes
reimburse employees for medical expenses not |
covered by health insurance. Did your
2
No
|
government unit offer an HRA associated with
|
this plan in 2011?
3
Don’t know
|
HRAs are NOT Flexible Spending Accounts (FSAs)
|
or Health Savings Accounts (HSAs).
|
|
See definition sheet for more information.
|
|
PLAN CHARACTERISTICS
|
| 183
Could this plan have refused to cover persons
1
|
Yes
with pre-existing medical or health conditions? |
|
2
No
|
|
| 185 1
Did this plan have a policy requiring a waiting
Yes
period before covering pre-existing conditions? |
|
2
No
|
|
|
Which of the services listed were covered by
|
this plan?
|
|
| 173 Chiropractic care . . . . . . . . . .
|
|
| 587 Routine vision care. . . . . . . . .
22. An employer can offer a Health Reimbursement
23.
24.
25.
|
|
|
176
Yes
(1)
No
(2)
Don’t
know
(3)
Routine dental care . . . . . . . .
*** PLEASE NOTE ***
29040078
If this is your last health insurance plan, please continue with the form MEPS-11(R),
Section C.
FORM MEPS-11(S) (03-09-2011)
§>%!o¤
If your government unit offered MORE THAN ONE health insurance plan, please fill
out a MEPS-11(S) for each plan that was offered. Then continue with the form
MEPS-11(R), at the back of this package.
OMB No. 0935-0110: Approval Expires 01/31/2013
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 2011.
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
2011 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)
2011 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
29071016
4a.
,
b.
c.
d.
570
,
Employee contribution for
employee-plus-one premium
637
Total employee-plus-one
premium
FORM MEPS-11C(S) (03-25-2011)
$
.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
§>(+1¤
3a.
2
GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
2011 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
1
Yes - Used TPA
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).
8a.
Complete questions 8a-b if this plan
was self-insured.
Did your government unit
employ a third party
administrator (TPA) for this
self-insured plan?
29071024
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) (03-25-2011)
113
113
§>(+9¤
SELF-INSURED PLAN INFORMATION
3
GENERAL PLAN INFORMATION
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
1
Yes
2
No
1
Yes
2
No
185
requiring a waiting period
before covering pre-existing
conditions?
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.
Mark (X) all that apply.
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
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
Employee contribution did
not vary
646
OR
Employee contribution did
not vary
646
HEALTH SAVINGS ACCOUNT (HSA)
15. If the deductibles for this plan
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 2011?
FORM MEPS-11C(S) (03-25-2011)
714
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
§>(+A¤
29071032
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 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
2011?
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.
29071040
REMEMBER TO ENCLOSE A COPY OF EACH PLAN BROCHURE WITH YOUR DATA SUBMISSION OR
PROVIDE THE BROCHURE WEBSITE ADDRESS WITH YOUR CONTACT INFORMATION ON THE
MEPS-11C(F) AS APPLICABLE. PLEASE PROVIDE THE GENERAL USER INFORMATION IN THE
REMARKS SECTION TO ACCESS THE BROCHURES, IF NEEDED AND AVAILABLE.
If you have any questions concerning this survey, please call 1-888-206-5068.
FORM MEPS-11C(S) (03-25-2011)
§>(+I¤
If you have completed your last health insurance plan, continue
with form MEPS-11C(R), Section C.
OMB No. 0935-0110: Approval Expires 01/31/2013
To:
Government:
ID:
From:
U.S. Census Bureau
Toll Free: (888) 206-5068
Please complete and either
Fax to: (888) 288-0305
or
Email:
1 of 3
Subject: 2011 Health Insurance Cost Study (critical items for 2011 plan year)
Thank you for agreeing to complete the following summary charts for the 2011 plan year.
Please note:
EE = EMPLOYEE-paid portion of the monthly premium.
TOT = TOTAL monthly premium (Census will subtract for employer portion.)
ENROLLMENT
2011 Active Employees
Single
Coverage
Plan
Name(s)
1)
Was this plan self-insured?
No
Was this plan self-insured?
No
Was this plan self-insured?
§>3+.¤
No
Was this plan self-insured?
No
Was this plan self-insured?
No
COBRA
Coverage
(All tiers)
(Family of 4)
(All tiers)
(All tiers)
Single
Coverage
EE + 1
Coverage
Family
Coverage
EE + Child(ren)/
Spouse
(Family of 4)
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
Don’t Know
5)
Yes
Total
Coverage
Don’t Know
4)
Yes
Family
Coverage
Don’t Know
3)
Yes
EE + 1
Coverage
Don’t Know
2)
Yes
MONTHLY PREMIUMS
Don’t Know
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.
FORM MEPS-GRID (03-01-2011)
29181013
Yes
Estimates are acceptable.
To:
Government:
ID:
From:
U.S. Census Bureau
Toll Free: (888) 206-5068
ENROLLMENT
2011 Active Employees
Single
Coverage
Plan
Name(s)
EE + 1
Coverage
Family
Coverage
Total
Coverage
COBRA
Coverage
(All tiers)
(Family of 4)
(All tiers)
(All tiers)
Was this plan self-insured?
Was this plan self-insured?
No
Was this plan self-insured?
No
§>3+6¤
Was this plan self-insured?
No
Was this plan self-insured?
No
(Family of 4)
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
EE
EE
EE
TOT
TOT
TOT
Don’t Know
10)
Yes
EE + Child(ren)/
Spouse
Don’t Know
9)
Yes
Family
Coverage
Don’t Know
8)
Yes
EE + 1
Coverage
Don’t Know
7)
Yes
Single
Coverage
Don’t Know
Estimates are acceptable.
Please include a comparison chart or summary of benefits for all 2011 medical plans when returning this grid. Thank you.
FORM MEPS-GRID (03-01-2011)
29181021
No
2 of 3
MONTHLY PREMIUMS
6)
Yes
Please complete and either
Fax to: (888) 288-0305
or
Email:
To:
Government:
ID:
From:
U.S. Census Bureau
Toll Free: (888) 206-5068
Please complete and either
Fax to: (888) 288-0305
or
Email:
Estimates are acceptable.
ENROLLMENT
2011 Retirees
Total Retirees
in all plans
3 of 3
MONTHLY PREMIUMS**
Percent Retirees
in Single coverage
Single
Coverage
Family
Coverage
(Family of 2)
Retirees UNDER 65
%
Retirees 65 + OVER
%
EE
EE
TOT
TOT
EE
EE
TOT
TOT
** List premiums for plan with highest enrollment.
§>3+H¤
2. In 2011, did you offer any of the following fringe benefits?
3. In 2011, did you offer any of these tax-advantaged benefits?
4. In 2011, did you offer any of these optional coverage
services to active employees at a premium SEPARATE
from the comprehensive health plan premium?
Paid Vacation
Yes
No
Paid Sick Leave
Yes
No
Life Insurance
Yes
No
Disability Insurance
Yes
No
Retirement/Pension plans
Yes
No
Pre-tax contrib. for Health Insurance
Yes
No
Flexible Spending Account
Yes
No
Dental
Yes
No
Vision
Yes
No
Prescription Drugs
Yes
No
Long-term Care
Yes
No
5. What was the total amount paid for optional coverage for all ACTIVE employees during a TYPICAL
MONTH at this government unit in 2011? (Include both employer and employee contributions.)
$
29181039
1. How many hrs/wk must an employee work to be eligible for health insurance?
.00
Please include a comparison chart or summary of benefits for all 2011 medical plans when returning this grid. Thank you.
FORM MEPS-GRID (03-01-2011)
OMB No. 0935-0110: Approval Expires 1/31/2013
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
Plan Information Questionnaire
GENERAL PLAN INFORMATION
Please complete this Plan Information Questionnaire for the representative plan with the largest (or next largest)
enrollment. Please select the plan which best represents all regions.
1.
For 2011, what was the name of the health
insurance plan with the largest (or next largest)
national enrollment of ACTIVE employees?
Examples: • Blue Cross Blue Shield, High Option
• Company Plan A
• Aetna, HMO
012
2.
Which type of health care provider arrangement
was available through this plan?
See the Definition Sheet included with this package for an
explanation of these plans.
103
Name of plan
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
3.
Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order to
be referred to a specialist?
104
For plans with multiple options, answer for the "in-network"
option.
4.
29101011
5.
Was this plan offered through a union or trade
association?
Was this plan purchased from an insurance
underwriter or was it self-insured?
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.
Self-insured – Your company 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.
113
1
Yes
2
No
3
Don’t know
1
Union
2
Trade association
3
Neither
1
Purchased – SKIP to Question 7a
on Page 2
2
Self-insured – Continue with Question 6a
3
Don’t know – SKIP to Question 7a
on Page 2
105
SELF-INSURED PLAN INFORMATION
Complete questions 6a-b if this plan was self-insured.
713
6a. Did your company employ a third party
administrator (TPA) for this self-insured plan?
b. Did your company purchase stop-loss coverage
for this plan?
FORM MEPS-15(S) (02-17-2011)
107
1
Yes – Used a third party administrator
2
No – Self-administered the plan
1
Yes
2
No
§>++,¤
(Examples: Most PPO and POS-type plans)
2
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
7a. How many ACTIVE employees were ENROLLED
in this plan during a typical pay period in 2011?
125
Include full-time, part-time, temporary and seasonal
employees.
Active employees enrolled in plan
Exclude former employees, leased or contract workers and
retirees.
b. How many of these ACTIVE employees were
129
Active employees enrolled in
single coverage
ENROLLED in SINGLE coverage during a typical
pay period in 2011?
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.
c. If your company offered EMPLOYEE-PLUS-ONE
571
Active employees enrolled in
employee-plus-one coverage
coverage, how many ACTIVE employees were
ENROLLED during a typical pay period in 2011?
Include enrollment for both employee-plus-spouse and
employee-plus-child(ren) coverage.
d. How many ACTIVE employees were ENROLLED
705
Active employees enrolled in
family coverage
in FAMILY (not single or employee-plus-one)
coverage during a typical pay period in 2011?
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 2011?
126
Former employees enrolled in
plan, excluding retirees
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 2011.
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.
552
9a. Was SINGLE coverage offered under this plan?
b. For this plan, how much did the EMPLOYER
1
Yes –Continue with Question 9b
2
No – SKIP to Page 3, Question 10a
131
29101029
contribute toward the plan premium of one
typical employee with SINGLE coverage?
c. How much did this typical EMPLOYEE with
$
$
based on which one of the following time
periods?
,
$
133
,
.00
Employee contribution for
single premium
.00
Total single premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Mark (X) only one.
FORM MEPS-15(S) (02-17-2011)
Employer contribution for
single premium
130
employee with SINGLE coverage?
e. The amounts reported in questions 9b-d are
.00
132
SINGLE coverage contribute toward his/her own
premium?
d. What was the TOTAL premium for this typical
,
§>++>¤
SINGLE COVERAGE
3
PLAN PREMIUMS – Continued
EMPLOYEE-PLUS-ONE COVERAGE
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 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
1
Yes – Continue with Question 10b
2
No – SKIP to Question 11a
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?
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
636
$
Employer contribution for
employee-plus-one
premium
.00
Employee contribution for
employee-plus-one
premium
.00
Total employee-plus-one
premium
637
$
,
635
$
employee with EMPLOYEE-PLUS-ONE coverage?
e. The amounts reported in questions 10b-d are
,
.00
638
based on which one of the following time
periods?
,
1
Weekly
2
Every 2 weeks
3
Monthly
5
Quarterly
4
Yearly
1
Yes – Continue with Question 11b
2
No – SKIP to Page 4, Question 12a
Mark (X) only one.
137
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
135
contribute toward the plan premium of one
typical employee with FAMILY coverage?
c. How much did this typical EMPLOYEE with
$
29101037
$
based on which one of the following time
periods?
$
553
.00
Employee contribution for
family premium
,
.00
Total family premium
1
Weekly
2
Every 2 weeks
3
Monthly
5
Quarterly
4
Yearly
Mark (X) only one.
FORM MEPS-15(S) (02-17-2011)
,
134
employee with FAMILY coverage?
e. The amounts reported in questions 11b-d are
Employer contribution for
family premium
136
FAMILY coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
,
.00
§>++F¤
FAMILY COVERAGE
4
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
OR
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
OR
646
Employee contribution did not vary
INDIVIDUAL DEDUCTIBLES
151
Deductibles – Predetermined amount which must be paid
by an individual before the plan will reimburse for covered
services.
Many HMOs do not have a deductible.
b. What was the annual deductible an individual
paid?
1
Yes –Continue with Question 13b
2
No – SKIP to Page 5, Question 16a
146
$
,
Report "IN-NETWORK" deductibles (if applicable).
DO NOT report COPAYMENTS or individual or family maximums
here.
Individual annual deductible
OR
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 16b on Page 5.
.00
Separate deductibles for:
147
$
,
.00
Physician care
148
$
,
.00
Hospital care
FAMILY DEDUCTIBLES
29101045
14a. Did this plan require that a specific number of
224
family members must meet their individual
deductibles before the family deductible was
met?
b. How many family members were required to
1
Yes – Continue with Question 14b
2
No – SKIP to Question 14c
3
Family coverage not offered –
SKIP to Page 5, Question 15
150
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?
Report for a family of four.
FORM MEPS-15(S) (02-17-2011)
Number of family members
149
$
,
.00
Total annual family deductible
§>++N¤
13a. Did this plan have a deductible?
5
HEALTH SAVINGS ACCOUNT (HSA)
15. If the deductibles you reported in questions 13
714
and 14 were $1,200 or higher for single coverage
and $2,400 or higher for family coverage, did your
company contribute to a Health Savings Account
(HSA) for the plan enrollees in 2011?
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA
4
Don’t know
1
Yes – Continue with Question 16b
2
No – SKIP to Question 16c
PAYMENTS
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
152
$
154
Some plans may have both a dollar copayment and a
percentage coinsurance.
Per day
2
Per stay
AND/OR
153
%
Do not include any physician charges incurred during the
hospital admission.
c. Was physician care covered under this plan?
d. How much and/or what percentage of the total
218
Yes – Continue with Question 16d
2
No – SKIP to Question 17
156
.00 Copayment paid by enrollee for
$
office visit
AND/OR
157
%
Report for an "in-network"/participating general practitioner
during normal office hours.
17. Were prescription drugs covered under this
673
29101052
health plan?
18. How many different pricing categories or tiers
Coinsurance paid by enrollee
1
Yes – Continue with Question 18
2
No
3
Don’t know
}
SKIP to Page 6, Question 20a
712
of prescription drug coverage were there for this
plan?
Number of tiers
715
FORM MEPS-15(S) (02-17-2011)
Coinsurance paid by enrollee
1
bill did an enrollee pay out-of-pocket for an office
visit after any annual deductible was met?
Out-of-pocket expense – Those costs paid directly by
the enrollee.
Some plans may have both a dollar copayment and a
percentage coinsurance.
hospital admission
1
Report for precertified hospital admissions (if applicable).
Report for an admission at an "in-network"/participating
hospital (if applicable).
.00 Copayment paid by enrollee for
,
Don’t know
§>++U¤
16a. Was hospital care covered under this plan?
6
PAYMENTS – Continued
19. How much and/or what percentage did an
enrollee pay out-of-pocket for the lowest tier of
prescription drug coverage?
Lowest cost to enrollee
655
$
Report for the least expensive pharmacy available to the
enrollee under the plan, excluding any mail-order programs.
.00
Copayment
AND/OR
677
%
Include all copayments, coinsurance, and deductibles.
161
$
20a. What was the MAXIMUM ANNUAL out-of-pocket
Out-of-pocket expense – Those costs paid directly by
the enrollee.
b. What was the MAXIMUM ANNUAL out-of-pocket
.00
,
expense for an individual?
This is often referred to as a catastrophic limit.
Coinsurance
OR
163
No individual maximum
162
expense for a family of four?
$
.00
,
OR
222
21. What was the MAXIMUM amount this plan would
No family maximum
160
have paid for an enrollee in ONE YEAR?
$
,
,
.00
OR
221
No annual maximum
22. 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 company
offer an HRA associated with this plan in 2011?
HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs).
29101060
See definition sheet for more information.
FORM MEPS-15(S) (02-17-2011)
710
1
Yes
2
No
3
Don’t know
§>++]¤
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
7
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 waiting
185
period before covering pre-existing conditions?
1
Yes
2
No
1
Yes
2
No
25. Which of the services listed were covered by
this plan?
173
Chiropractic care . . . . . . . . . . . . . . . .
587
Routine vision care . . . . . . . . . . . . . .
176
Routine dental care . . . . . . . . . . . . . .
Yes
No
Don’t
know
(1)
(2)
(3)
*** PLEASE NOTE ***
29101078
§>++o¤
Please complete the MEPS-15(E) Establishment Worksheet when
you have completed all applicable MEPS-15(S) Plan Information
Questionnaires.
If your company 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-15(S) (02-17-2011)
| File Type | application/pdf |
| File Title | meps10sp1_11.g |
| File Modified | 2011-07-15 |
| File Created | 2011-07-15 |