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pdfOMB No. 0935-0110: Approval Expires 12/31/2014
2013 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
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 (03-08-2013)
§>"?3¤
29013018
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address:
https://respond.census.gov/meps
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 2013.
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 (03-08-2013)
§>"?;¤
29013026
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 2013?
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 2013 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 2013; 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, 2008 and December 31,
2012?
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
29013034
§>"?C¤
Continue with Page 4, Section C
FORM MEPS-10 (03-08-2013)
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 2013?
034
Employees at all locations
Complete Questions 2–8 for THE LOCATION listed on
the cover sheet.
200
2a. How many employees were on your
All employees at this location
organization’s payroll AT THIS LOCATION
for a TYPICAL pay period in 2013?
b. How many of these employees were ELIGIBLE
If your organization did not offer health
insurance in 2013, 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 2013, 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 2013, 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 2013?
Enrolled part-time employees
564
1
Yes
2
No
4
Organization has no temporary or
seasonal employees
3
Don’t know
1
Information for specified location
2
Information for multiple locations
29013042
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 2013, SKIP to Page 5, Question 7a
6.
If your organization 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 (03-08-2013)
626
721
Minimum hours worked per week to be
eligible
No minimum number of hours required
§>"?K¤
b. How many of these part-time employees were
5
Section C – EMPLOYMENT CHARACTERISTICS - Continued
Provide information for a TYPICAL pay period in 2013.
Estimates are acceptable.
The following workforce characteristics are used to group
similar organizations together for analytical purposes.
7a. Approximately what percentage of the
018
employees at this location were union members?
%
729
b. Approximately what percentage of the
Union members
No union members
016
%
employees at this location were women?
Women employees
If none, enter "0".
c. Approximately what percentage of the
017
employees at this location were 50 years old
or older?
%
Employees 50 years old or older
If none, enter "0".
If none, enter "0".
d. For the employees at this location in 2013,
approximately what percentage earned –
Less than $11.50 per hour? . . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
Between $11.50 and $27.00 per hour? . . . . . . . . . .
Approximately $24,000 to $56,000 a year
More than $27.00 per hour? . . . . . . . . . . . . . . . . . . .
Approximately $56,000 a year or more
8.
For the employees at this location in 2013,
approximately how many earned more than
$42.00 per hour?
Approximately $87,000 a year or more
022
%
Earned less than $11.50 per hour
023
%
Earned between $11.50 and $27.00
per hour
024
%
726
Earned more than $27.00 per hour
Number of employees that
earned more than $42.00 per hour
29013059
§>"?\¤
Continue with Page 6, Section D
FORM MEPS-10 (03-08-2013)
6
Section D – BUSINESS CHARACTERISTICS
1a. Did your organization offer the following fringe
benefits to its employees at this location in
2013?
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 2013?
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
Yes
No
Don’t
know
(1)
(2)
(3)
Yes
No
Don’t
know
(1)
(2)
(3)
Full cafeteria plans that offer
employees a set of benefits
from which to choose.
Continue with Page 7, Section E
If your organization DID offer health insurance coverage to its
employees in 2013, continue to Page 7, Section E.
29013067
§>"?d¤
If your organization DID NOT offer health insurance coverage to
its employees in 2013, SKIP to Page 8, Section F.
FORM MEPS-10 (03-08-2013)
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 2013 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 2
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 2013?
$
3.
For 2013, did your organization impose a waiting
period before new employees could be covered
by health insurance?
Did your organization provide any financial
compensation or incentives to employees if
they did not elect to receive health insurance
coverage?
4a. Did your organization offer health insurance
197
723
730
coverage to unmarried domestic partners of the
SAME sex?
b. Did your organization offer health insurance
731
29013075
coverage to unmarried domestic partners of the
OPPOSITE sex?
If your organization has 50 or more employees,
SKIP to Page 8, Section F.
5.
If your organization has less than 50 employees,
will your organization claim a Small Business
Health Care Tax Credit on its 2013 federal
taxes?
A small employer may be eligible for this credit on its
federal income taxes if 1.) it has fewer than 25 full-time
equivalent employees, 2.) pays an average wage of less
than $50,000 per year, and 3.) pays at least half of the
health insurance premiums for its employees.
,
.00
Monthly optional coverage cost
Include both employer and employee contributions.
2.
,
728
1
Yes
2
No
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Organization not eligible
4
Don’t know
Continue with Page 8, Section F
FORM MEPS-10 (03-08-2013)
§>"?l¤
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 2013 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 2013, 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?
29013083
Employer contribution for
single premium
575
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2013, 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 (03-08-2013)
§>"?t¤
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 2013, 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 2013, 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 2013.
630
Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.
5a. Did your organization offer health insurance to
29013091
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 (03-08-2013)
§>"?|¤
NEW RETIREES
10
500 Remarks
Section G – PERSON COMPLETING THIS QUESTIONNAIRE
*** PLEASE NOTE ***
§>"@*¤
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.
29013109
If your organization DID NOT offer health insurance, please complete
Section G and END the form.
212
213
Name (Please print)
Title (Please print)
Signature
214
Date (Month/Day/Year)
2 0
215
220
Telephone number
–
FORM MEPS-10 (03-08-2013)
Extension
216
Fax
–
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
OMB No. 0935-0110: Approval Expires 12/31/2014
2013 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) (12-03-2012) Draft 1
§>$?1¤
29033016
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address:
https://respond.census.gov/meps11
Your Survey Key to access the Internet form is:
2
INSTRUCTIONS
1. Please report for the government unit identified on the cover sheet.
2. Please report data for the year 2013.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the definition sheet
included with this package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a completed copy of this form for your records.
7. If you have any questions or need assistance in completing the
questionnaire, please call 1-888-273-3878.
Paperwork Reduction Act and Burden Statements
We expect that it will take 45 minutes, on average, to complete the basic questionnaire. If you offered more than one plan, we
expect it will take an additional 10 minutes per plan, on average. In addition, we estimate that it will take 15 minutes to review
the instructions and locate the requested information. You may send any comments regarding this burden estimate or any other
aspect of the collection of information, including suggestions for reducing burden, to the following address: Director, Center for
Financing, Access and Cost Trends, Paperwork Reduction Project 0935-0110, Agency for Healthcare Research and Quality,
Room 5030, 540 Gaither Road, Rockville, MD 20850. Please do not mail questionnaires to this address as it will delay data
processing. If the enclosed mailing envelope has been misplaced, please use address on front page of form to return questionnaire.
FORM MEPS-11(F) (12-03-2012)
§>$?9¤
29033024
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 2013?
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 2013 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
29033032
§>$?A¤
500
Continue with Section B, MEPS-11(S)
FORM MEPS-11(F) (12-03-2012)
OMB No. 0935-0110: Approval Expires 12/31/2014
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Medical Expenditure Panel Survey - Insurance Component
HEALTH INSURANCE COST STUDY
Government Unit Questionnaire
Section C - RETIREE HEALTH COVERAGE CHARACTERISTICS
government unit provide health insurance
coverage to any person who retired from your
government unit in 2013 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 2013, 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
29053014
monthly premium for this typical retiree with
SINGLE coverage?
f. For a typical plan in 2013, 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) (02-13-2013) Draft 6
Yes - This government unit - Continue with
Question 2
Yes - Another government unit
1
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
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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
$
.00 Total single
,
premium
Government unit
576
$
.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
§>&?/¤
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 2013, 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
$
.00 Total single
,
premium
Government unit
$
.00 contribution for
,
family premium
583
$
monthly premium for this typical retiree with
FAMILY coverage?
h. Did a typical plan provide coverage for
single premium
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
,
581
monthly premium for this typical retiree with
SINGLE coverage?
f. For a typical plan in 2013, how much did the
.00 contribution for
725
outpatient prescription drugs for retirees
65 years of age or over?
.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 2013.
5a. Did your government unit offer health insurance
to any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
29053022
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) (02-13-2013)
§>&?7¤
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,
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
2a. Did your government unit offer health
$
,
.00
730
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
731
insurance coverage to unmarried domestic
partners of the OPPOSITE sex?
For 2013, did your government unit impose a
waiting period before new employees could be
covered by health insurance?
,
Monthly optional coverage cost
insurance coverage to unmarried domestic
partners of the SAME sex?
b. Did your government unit offer health
Continue with Question 1b
720
coverage for all ACTIVE employees at THIS
GOVERNMENT UNIT during a typical month in
2013?
3.
}
if any, did your government unit offer to its
ACTIVE employees in 2013 at a premium
SEPARATE from the comprehensive health
plan premium?
197
Section E - EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include part-time, temporary, and seasonal employees.
Exclude leased or contract workers and retirees.
740
government unit’s payroll for a TYPICAL pay
period in 2013?
b. How many of these ACTIVE employees were
All employees
201
29053030
ELIGIBLE for at least one health plan through
your government unit?
c. How many of these ACTIVE employees were
ENROLLED in ANY health plan through your
government unit?
FORM MEPS-11(R) (02-13-2013)
Eligible employees
202
Enrolled employees
§>&??¤
1a. How many ACTIVE employees were on your
4
|
Section E – EMPLOYMENT CHARACTERISTICS - Continued
2a. For the same typical pay period in 2013, did
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
Eligible part-time employees
205
ENROLLED in ANY health plan through your
government unit?
3.
4.
Did your government unit offer health insurance
to its temporary or seasonal employees in
2013?
Mark (X) only one.
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
}
Enrolled part-time employees
1
Yes
4
Government unit
has no temporary or
seasonal employees
2
No
3
Don’t know
564
626
Minimum hours worked per
week to be eligible
721
No minimum number of hours required
Section F – FRINGE BENEFITS
CHARACTERISTICS
|
Yes
fringe benefits to its employees in 2013?
(1)
050
Paid vacation. . . . . . . . . . . . . . . .
051
Paid sick leave. . . . . . . . . . . . . . .
052
Life insurance . . . . . . . . . . . . . . .
053
Disability insurance. . . . . . . . . . . .
054
Retirement/pension plans . . . . . . .
2. Did your government unit offer any of these
Yes
29053048
tax-advantaged benefits to its employees in
2013?
(1)
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
Don’t
No know
(2)
(3)
Don’t
No know
(2)
(3)
Continue with Page 5, Section G
FORM MEPS-11(R) (02-13-2013)
§>&?Q¤
1. Did your government unit offer the following
5
Section G - EMPLOYEE CHARACTERISTICS
Provide information for a typical pay period
in 2013.
Estimates are acceptable.
The following workforce characteristics are used to
group similar government units together for analytical
purposes.
1a. Approximately what percentage of the
018
employees at this government unit were
union members?
%
729
b. Approximately what percentage of the
No union members
016
employees at this government unit were
women?
If none, enter "0".
c. Approximately what percentage of the
Union members
%
Women employees
017
%
employees at this government unit were 50
years old or older?
If none, enter "0".
Employees 50 years old or older
If none, enter "0".
2. For the employees at this government unit in
2013, 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 $27.00 per hour?. . . . . . . .
Approximately $24,000 to $56,000 a year
% Earned between $11.50 and
$27.00 per hour
024
More than $27.00 per hour? . . . . . . . . . . . . . . . . .
Approximately $56,000 a year or more
%
Earned more than $27.00 per hour
3. For the employees at this government unit
726
Number of employees that
earned more than $42.00 per hour
Section H - PERSON COMPLETING THIS QUESTIONNAIRE
29053055
212
Name (Please print)
213
Title (Please print)
Signature
214
Date (Month/Day/Year)
2 0
215
220
Telephone number
–
Extension
216
Fax
–
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS.
FORM MEPS-11(R) (02-13-2013)
§>&?X¤
in 2013, how many earned more than
$42.00 per hour?
Approximately $87,000 a year or more
OMB No. 0935-0110: Approval Expires 12/31/2014
2013 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-11C(F) (12-03-2012) Draft 1
§>’?.¤
29063013
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address:
https://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. Report data for the year 2013.
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.
29063021
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) (12-03-2012)
§>’?6¤
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 2013?
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
003
choices did your government unit make
available or contribute to for its ACTIVE
employees during the 2013 plan year?
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.
671
c. Are health benefits brochures for those plans
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
§>’?H¤
500
1
CONTACT INFORMATION – PERSON COMPLETING THIS QUESTIONNAIRE
29063039
212
Name (Please print)
Signature
215
220
Telephone number
–
670
Extension
213
Title (Please print)
217
Email (Please print)
216
Fax
–
Brochure Website address
214
http: //
FORM MEPS-11C(F)
(12-03-2012)
Date (Month/Day/Year)
2 0
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
OMB No. 0935-0110: Approval Expires 12/31/2014
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Medical Expenditure Panel Survey – Insurance Component
HEALTH INSURANCE COST STUDY
Government Unit Questionnaire
Section C – RETIREE HEALTH COVERAGE CHARACTERISTICS
Exclude any retirees that have coverage
through PHSA (COBRA) or state
continuation-of-benefits laws.
If this is a self-insured plan, report the premium
equivalent.
For an explanation of these terms, see the definition
sheet included with this package.
Did your government unit or some other
government unit provide health insurance
coverage to any person who RETIRED
from your government unit in 2013 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 Page 3, Section D
513
Number of retirees enrolled
29083011
§>)?,¤
Continue with Page 2, Question 3a
FORM MEPS-11C(R) (02-13-2013) Draft 8
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 – SKIP to
Question 4a
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 2013, 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 2013, how much did
629
572
TOTAL number of retirees, by age
category, enrolled in health insurance
through your government unit in 2013?
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
29083029
NEW RETIREES
For Questions 4a through 4c, NEW RETIREES
refers to persons who retired from your government
unit in 2013.
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) (02-13-2013)
632
}
SKIP to Section D
§>)?>¤
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 2013 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 Question 2a
b. What was the total amount paid for OPTIONAL
720
COVERAGE for all ACTIVE employees during a
TYPICAL MONTH at THIS GOVERNMENT UNIT in
2013?
Include both employee and government unit contributions.
2a. Did your government unit offer health
$
,
,
.00
Monthly optional coverage cost
730
insurance coverage to unmarried domestic
partners of the SAME sex?
b. Did your government unit offer health
Continue with Question 1b
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
731
insurance coverage to unmarried domestic
partners of the OPPOSITE sex?
Section E – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility, and
enrollment figures.
Include full-time, part-time, temporary, and seasonal
employees.
How many ACTIVE employees were on your
government unit’s payroll for a TYPICAL pay
period in 2013?
740
b. How many of these ACTIVE employees were
201
All employees
ELIGIBLE for at least one health plan through
your government unit in 2013?
c. How many of these ACTIVE employees were
Eligible employees
202
29083037
ENROLLED in ANY health plan through your
government unit?
2a. Did your government unit have any PART-TIME
Enrolled employees
563
employees in 2013?
b. How many of these PART-TIME employees were
ENROLLED in ANY health plan through your
government unit?
Yes – Continue with Question 2b
2
No
3
Don’t know
}
SKIP to Page 4, Question 3
204
ELIGIBLE for at least one health plan through your
government unit?
c. How many of these PART-TIME employees were
1
Eligible part-time employees
205
Enrolled part-time employees
Continue with Page 4, Question 3
FORM MEPS-11C(R) (02-13-2013)
§>)?F¤
1a.
4
Section E – EMPLOYMENT CHARACTERISTICS - Continued
3.
Did your government unit offer health insurance
to its temporary or seasonal employees in 2013?
564
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?
1
Yes
2
No
4
Government unit has no temporary
or seasonal employees
3
Don’t know
626
Minimum hours worked
per week to be eligible
721
No minimum number of hours required
Section F – FRINGE BENEFITS CHARACTERISTICS
1.
2.
Did your government unit offer the following
fringe benefits to its employees in 2013?
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
2013?
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
2013.
29083045
The following workforce characteristics are used to group
similar government units together for analytical purposes.
1a. Approximately what percentage of the employees
018
at this government unit were union members?
%
Union members
729
No union members
b. Approximately what percentage of the employees
016
at this government unit were women?
%
If none, enter "0".
c. Approximately what percentage of the employees
at this government unit were 50 years old or
older?
Women employees
017
%
Employees 50 years old or older
If none, enter "0".
Continue with Page 5, Question 2
FORM MEPS-11C(R) (02-13-2013)
§>)?N¤
Estimates are acceptable.
5
Section G – EMPLOYEE CHARACTERISTICS - Continued
If none, enter "0".
2.
For the employees at this government unit in
2013, approximately what percentage earned –
Less than $11.50 per hour?. . . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
Between $11.50 and $27.00 per hour? . . . . . . . . . . .
Approximately $24,000 to $56,000 a year
022
%
023
%
%
Earned more than $27.00 per hour
726
Number of employees that
earned more than $42.00 per hour
29083052
§>)?U¤
For the employees at this government unit in
2013, approximately how many earned more
than $42.00 per hour?
Approximately $87,000 a year or more
Earned between $11.50 and $27.00
per hour
024
More than $27.00 per hour? . . . . . . . . . . . . . . . . . . . .
Approximately $56,000 a year or more
3.
Earned less than $11.50 per hour
FORM MEPS-11C(R) (02-13-2013)
OMB No. 0935-0110: Approval Expires 12/31/2014
2013 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
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 (01-30-2013) Draft 9
§>*?+¤
29093010
INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address:
https://respond.census.gov/meps
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 2013.
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://bhs.econ.census.gov/bhs/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 (01-30-2013)
§>*?=¤
29093028
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 2013 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 2013?
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 2013 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.
29093036
• An HMO and a conventional plan from the same
insurance company count as two plans.
FORM MEPS-15 (01-30-2013)
Continue with Page 4, Section B
§>*?E¤
• 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 2013?
Employees at all locations
If your company did not offer health
insurance in 2013, 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 2013, how
203
many of the employees reported in Question 1a
worked part-time?
Part-time employees
If your company did not offer health
insurance in 2013, 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 2013?
1
Yes
Mark (X) only one.
2
No
4
Company has no temporary
or seasonal employees
3
Don’t know
4. If your company offered health insurance, what
29093044
is the minimum number of hours per week that
an employee must work in order to be eligible
for health insurance?
626
721
Minimum hours worked per
week to be eligible
No minimum number of hours required
Continue with Page 5, Question 5
FORM MEPS-15 (01-30-2013)
§>*?M¤
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 2013,
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 2013.
Estimates are acceptable.
The following workforce characteristics are used to group
similar companies together for analytical purposes.
6a. Approximately what percentage of the total
018
employees at your company were union
members?
%
729
b. Approximately what percentage of the total
No union members
016
employees at your company were women?
%
If none, enter "0".
c. Approximately what percentage of the total
Union members
Women employees
017
employees at your company were 50 years old
or older?
%
Employees 50 years old or older
If none, enter "0".
If none, enter "0".
d. For the employees at your company in 2013,
approximately what percentage earned –
29093051
Between $11.50 and $27.00 per hour?. . . . . . . . . .
Approximately $24,000 to $56,000 a year
More than $27.00 per hour? . . . . . . . . . . . . . . . . . . .
Approximately $56,000 a year or more
7.
For the employees at your company in
2013, approximately how many earned
more than $42.00 per hour?
Approximately $87,000 a year or more
022
%
Earned less than $11.50 per hour
023
% Earned between $11.50 and $27.00
per hour
024
%
Earned more than $27.00 per hour
726
Number of employees that
earned more than $42.00 per hour
Continue with Page 6, Section C
FORM MEPS-15 (01-30-2013)
§>*?T¤
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 2013?
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
2013?
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
29093069
§>*?f¤
Continue with Page 7, Section D
FORM MEPS-15 (01-30-2013)
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 2013 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
2013?
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 2013, 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?
29093077
single premium
575
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2013, 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 with Page 8, Question 4a
FORM MEPS-15 (01-30-2013)
§>*?n¤
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 2013?
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 2013, 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 2013, 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 2013.
630
Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.
5a. Did your company offer health insurance to any
29093085
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 (01-30-2013)
§>*?v¤
NEW RETIREES
9
Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS
1a. Which of the listed optional coverage services,
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 2
b. What was the total amount paid for optional
$
3.
Did your company provide any financial
compensation or incentives to employees if
they did not elect to receive health insurance
coverage?
4a. Did your organization offer health insurance
197
723
730
coverage to unmarried domestic partners of
the SAME sex?
b. Did your organization offer health insurance
coverage to unmarried domestic partners of
the OPPOSITE sex?
,
,
.00
Monthly optional coverage cost
Include both employer and employee contributions.
For 2013, did your company impose a waiting
period before new employees could be covered
by health insurance?
Continue with Question 1b
720
coverage for all ACTIVE employees during a
TYPICAL MONTH at your company in 2013?
2.
}
if any, did your company offer to its ACTIVE
employees in 2013 at a premium SEPARATE
from the comprehensive health plan premium?
Report single service insurance plans only.
731
1
Yes
2
No
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
29093093
§>*?~¤
Continue with Page 10, Section F
FORM MEPS-15 (01-30-2013)
10
500
Remarks
Section F – PERSON COMPLETING THIS QUESTIONNAIRE
*** PLEASE NOTE ***
29093101
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)
Signature
214
Date (Month/Day/Year)
2 0
215
220
Telephone number
–
FORM MEPS-15 (01-30-2013)
Extension
216
Fax
–
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 12/31/2014
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Medical Expenditure Panel Survey - Insurance Component
HEALTH INSURANCE COST STUDY
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
2013. 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
29113016
(a)
FORM MEPS-15(E) (12-07-2012) Draft 5
Name of location
(b)
Have you
answered for
this location
on the
MEPS-15?
(c)
524
Number
of
employee(s)
200
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
(d)
Types of provider
arrangements offered
(Mark (X) all that apply)
HMO/ Conventional PPO/
EPO
POS
Indemnity
521 (e) 522 (f)
523 (g)
§>,?1¤
CENSUS USE ONLY
Location
Identification Number
29113024
(a)
FORM MEPS-15(E) (12-07-2012)
Name of location
(b)
Have you
answered for
this location
on the
MEPS-15?
(c)
524
Number
of
employee(s)
200
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
(d)
Types of provider
arrangements offered
(Mark (X) all that apply)
HMO/ Conventional PPO/
Indemnity
POS
EPO
521 (e) 522 (f)
523 (g)
§>,?9¤
CENSUS USE ONLY
| File Type | application/pdf |
| File Modified | 2013-08-29 |
| File Created | 2013-08-29 |