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pdfOMB 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
2013 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2013 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 2013, 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.
29023017
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) (03-07-2013)
§>#?2¤
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-c if this plan was self-insured.
6a. Did your organization employ a third party
713
administrator (TPA) or purchase administrative
services only (ASO) from an insurer for this
self-insured plan?
b. Did your organization purchase stop-loss
Yes - Used a TPA or ASO
2
No - Self-administered the plan
1
Yes
2
No - SKIP to Question 7a
107
coverage for this plan?
c. What was the specific stop-loss amount per
1
732
$
employee?
,
,
.00
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
7a. How many ACTIVE employees at this location
125
were ENROLLED in this plan during a typical
pay period in 2013?
Active employees enrolled
in plan
Include full-time, part-time, temporary and seasonal
employees.
Exclude former employees, leased or contract workers
and retirees.
129
29023025
ENROLLED in SINGLE coverage during a
typical pay period in 2013?
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 2013?
571
Active employees enrolled
in single coverage
Active employees enrolled
in employee-plus-one
coverage
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 2013?
705
Active employees enrolled
in family coverage
Continue with Page 3, Question 8
FORM MEPS-10(S) (03-07-2013)
§>#?:¤
b. How many of these ACTIVE employees were
3
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 2013?
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 2013.
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
.00 Total single
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.
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?
29023033
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?
636
$
637
$
,
Employee
contribution for
.00 employee-plus-one
premium
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
Mark (X) only one.
FORM MEPS-10(S) (03-07-2013)
,
Employer
contribution for
.00 employee-plus-one
premium
§>#?B¤
EMPLOYEE-PLUS-ONE 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
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 Total family
premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Mark (X) only one.
12a. Did the PREMIUMS for this insurance plan
vary by any of these characteristics?
138
Age. . . . . . . . . . . . . . . . . . . . .
139
Gender . . . . . . . . . . . . . . . . . .
141
Wage or salary levels . . . . . . .
733
Smoker/Non-smoker status . . .
142
Other. . . . . . . . . . . . . . . . . . . .
b. Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?
29023041
Do not include incentive programs that do not impact
contributions.
FORM MEPS-10(S) (03-07-2013)
641
Hours worked . . . . . . . . . . . . .
642
Union status . . . . . . . . . . . . . .
643
Wage or salary levels . . . . . . .
644
Occupation . . . . . . . . . . . . . . .
706
Length of employment. . . . . . .
734
Participation in a fitness/weight
loss program . . . . . . . . . . . . . .
735
Participation in a smoking
cessation program. . . . . . . . . .
645
Other. . . . . . . . . . . . . . . . . . . .
Yes
No
Don’t
know
(1)
(2)
(3)
Yes
No
Don’t
know
(1)
(2)
(3)
§>#?J¤
GENERAL PREMIUM INFORMATION
5
INDIVIDUAL DEDUCTIBLES
13a. Did this plan have a deductible?
151
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.
b. What was the annual deductible an individual
1
Yes - Continue with Question 13b
2
No - SKIP to Question 16a
146
$
paid?
Report "IN-NETWORK" deductibles (if applicable).
.00 Individual annual
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
Question 16b on Page 6.
,
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
$
Report for a family of four.
,
.00 Total annual family
deductible
15.
If the deductibles you reported in Questions
13 and 14 were $1,250 or higher for single
coverage and $2,500 or higher for family
coverage, did your organization contribute
to a Health Savings Account (HSA) for the
plan enrollees in 2013?
714
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA
4
Don’t know
29023058
PAYMENTS
16a. Was hospital care covered under this plan?
FORM MEPS-10(S) (03-07-2013)
155
1
Yes - Continue with Page 6, Question 16b
2
No - SKIP to Page 6, Question 16c
§>#?[¤
HEALTH SAVINGS ACCOUNT (HSA)
6
PAYMENTS - Continued
16b. 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.
$
154
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).
Copayment paid by
enrollee for hospital
admission
152
.00
,
1
Per day
2
Per stay
AND/OR
153
Coinsurance
paid by enrollee
%
Report for an admission at an "in-network"/participating
hospital (if applicable).
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
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.
Were prescription drugs covered under this
health plan?
673
1
Yes
2
No
Don’t know
3
18.
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 19a
Lowest cost to enrollee
655
$
.00
Copayment
AND/OR
677
%
Coinsurance
29023066
Include all copayments, coinsurance and deductibles.
19a. What was the MAXIMUM ANNUAL
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?
,
.00
OR
222
No family maximum
Continue with Page 7, Question 20
FORM MEPS-10(S) (03-07-2013)
§>#?c¤
17.
7
PLAN CHARACTERISTICS
20. Could this plan have refused to cover persons
183
with pre-existing medical or health conditions?
21. Did this plan have a policy requiring a
1
Yes
2
No
1
Yes
2
No
185
waiting period before covering pre-existing
conditions?
22. Which of the services listed were covered by
this plan?
23. Was this a grandfathered health plan as defined
by the Affordable Care Act?
See the definition sheet included with this package for an
explanation.
173
Chiropractic care . . . . . . . . . . . .
736
Routine vision care for children .
587
Routine vision care for adults . .
737
Routine dental care for children .
176
Routine dental care for adults . .
738
Mental health care . . . . . . . . . . .
182
Substance abuse treatment . . . .
739
1
Yes
2
No
3
Don’t know
Yes
No
Don’t
know
(1)
(2)
(3)
29023074
If your organization offered only one health insurance plan,
you have completed your response to this survey.
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) (03-07-2013)
§>#?k¤
*** PLEASE NOTE ***
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
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health
insurance plans offered in 2013 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 2013, 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
29043015
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
2
No
3
Don’t know
For plans with multiple options, answer for the "in-network"
option.
Continue with Page 2, Question 4
FORM MEPS-11(S) (01-24-2013) Draft 4
§>%?0¤
was available through this plan?
2
GENERAL PLAN INFORMATION
- Continued
|
4. Was this plan purchased from an insurance
105
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 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.
1
Purchased - SKIP to Question 6a
2
Self-insured - Continue with Question 5a
3
Don’t know - SKIP to Question 6a
SELF-INSURED PLAN
INFORMATION
|
Complete Questions 6a-c if this plan was self-insured.
713
5a. Did your government unit employ a third party
administrator (TPA) or purchase administrative
services only (ASO) from an insurer for this
self-insured plan?
b. Did your government unit purchase stop-loss
1
Yes - Used a TPA or ASO
2
No - Self-administered the plan
1
Yes
2
No - SKIP to Question 6a
107
coverage for this plan?
c. What was the specific stop-loss amount per
732
$
employee?
,
,
.00
|
ACTIVE ENROLLMENT
|
Estimates are acceptable for all enrollment figures.
6a. How many ACTIVE employees were
125
Active employees enrolled
in plan at this government unit
129
Active employees enrolled
in single coverage
571
Active employees enrolled
in employee-plus-one
coverage
705
Active employees enrolled
in family coverage
ENROLLED in this plan at this government
unit during a typical pay period in 2013?
Include full-time, part-time, temporary and seasonal
employees.
b. How many of these ACTIVE employees were
29043023
ENROLLED in SINGLE coverage during a typical
pay period in 2013?
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 government unit offered
EMPLOYEE-PLUS-ONE coverage, how many
ACTIVE employees were ENROLLED during a
typical pay period in 2013?
Include enrollment for both employee-plus-spouse and
employee-plus-child(ren) coverage.
d. How many of these ACTIVE employees were
ENROLLED in FAMILY (not single or
employee-plus-one) coverage during a typical
pay period in 2013?
Continue with Page 3, Question 7
FORM MEPS-11(S) (01-24-2013)
§>%?8¤
Exclude retirees, former employees, leased or contract
workers.
3
PHSA (COBRA) ENROLLMENT
7.
How many FORMER employees were ENROLLED
in this plan, excluding retirees, through PHSA
(COBRA) or state continuation-of-benefits laws
during a typical pay period in 2013?
126
Former employees enrolled
in plan, excluding retirees
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 2013.
Include any employer contributions to an HSA account in the employer contribution for premiums.
SINGLE COVERAGE
552
8a. Was SINGLE coverage offered under this plan?
b. For this plan, how much did the GOVERNMENT
1
Yes - Continue with Question 8b
2
No - SKIP to Question 9a
131
$
UNIT contribute toward the plan premium of
one typical employee with SINGLE coverage?
c. How much did this typical EMPLOYEE with
Employee
132
$
SINGLE coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
,
.00 contribution for
single premium
130
$
employee with SINGLE coverage?
e. The amounts reported in Questions 9b-d are
,
Government unit
.00 contribution for
single premium
133
based on which one of the following time
periods?
Mark (X) only one.
Total single
,
.00 premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
1
Yes - Continue with Question 9b
2
No - SKIP to Page 4, Question 10a
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
9a. Was EMPLOYEE-PLUS-ONE coverage offered
under this plan?
b. For this plan, how much did the GOVERNMENT
UNIT contribute toward the plan premium of
one typical employee with EMPLOYEEPLUS-ONE coverage?
29043031
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
$
637
$
based on which one of the following time
periods?
Mark (X) only one.
FORM MEPS-11(S) (01-24-2013)
,
$
638
Employee
contribution for
.00 employee-plus-one
premium
Total
635
employee with EMPLOYEE-PLUS-ONE
coverage?
e. The amounts reported in Questions 10b-d are
,
Government unit
contribution for
.00 employee-plus-one
premium
,
.00 employee-plus-one
premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Continue with Page 4, Question 10a
§>%?@¤
EMPLOYEE-PLUS-ONE COVERAGE
4
PLAN PREMIUMS
- Continued
|
FAMILY COVERAGE
137
1
Yes - Continue with Question 10b
2
No - SKIP to Question 11a
If premium varied by family size, report for a family of four.
10a. Was FAMILY coverage offered under this plan?
b. For this plan, how much did the GOVERNMENT
Government unit
135
$
UNIT contribute toward the plan premium of
one typical employee with FAMILY coverage?
c. How much did this typical EMPLOYEE with
,
family premium
Employee
136
$
FAMILY coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
.00 contribution for
,
.00 contribution for
family premium
134
employee with FAMILY coverage?
$
e. The amounts reported in Questions 10b-d are
553
based on which one of the following time
periods?
Total family
,
.00 premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Mark (X) only one.
11a. Did the PREMIUMS for this insurance plan
vary by any of these characteristics?
138
Age. . . . . . . . . . . . . . . . . . . . .
139
Gender . . . . . . . . . . . . . . . . . .
141
Wage or salary levels . . . . . . .
733
Smoker/Non-smoker status . . .
142
Other. . . . . . . . . . . . . . . . . . . .
b. Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?
29043049
Do not include internal incentive programs that do not
impact contributions.
|
FORM MEPS-11(S) (01-24-2013)
641
Hours worked . . . . . . . . . . . . .
642
Union status . . . . . . . . . . . . . .
643
Wage or salary levels . . . . . . .
644
Occupation . . . . . . . . . . . . . . .
706
Length of employment. . . . . . .
734
Participation in a fitness/weight
loss program . . . . . . . . . . . . . .
735
Participation in a smoking
cessation program. . . . . . . . . .
645
Other. . . . . . . . . . . . . . . . . . . .
Yes
No
Don’t
know
(1)
(2)
(3)
Yes
No
Don’t
know
(1)
(2)
(3)
§>%?R¤
GENERAL PREMIUM INFORMATION
5
|
INDIVIDUAL DEDUCTIBLES
12a. Did this plan have a deductible?
151
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.
b. What was the annual deductible an individual
1
Yes - Continue with Question 12b
2
No - SKIP to Question 15a
146
paid?
$
.00 Individual annual
,
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.
147
$
If deductible is per overnight hospital stay, it is not an
annual deductible and should be reported under
Question 16b on Page 6.
,
.00
Physician care
148
$
DO NOT report COPAYMENTS or individual or family
maximums here.
,
.00
Hospital care
FAMILY DEDUCTIBLES
224
13a. Did this plan require that a specific number
of family members meet their individual
deductibles before the family deductible
was met?
b. How many family members were required to
1
Yes - Continue with Question 13b
2
No - SKIP to Question 13c
3
Family coverage not offered - SKIP to
Question 14
150
meet their individual deductibles before the
family deductible was met?
Number of family members
Report for a family of four.
c. What was the total annual deductible a
149
$
family paid?
Report for a family of four.
,
.00 Total annual family
deductible
HEALTH SAVINGS| ACCOUNT (HSA)
14.
714
If the deductibles you reported in Questions 12
and 13 were $1,250 or higher for single
coverage and $2,500 or higher for family
coverage, did your government unit contribute
to a Health Savings Account (HSA) for the plan
enrollees in 2013?
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA
4
Don’t know
|
PAYMENTS
29043056
|
15a. Was hospital care covered under this plan?
FORM MEPS-11(S) (01-24-2013)
155
1
Yes - Continue with Question 15b on Page 6
2
No - SKIP to Page 6, Question 15c
§>%?Y¤
|
6
PAYMENTS | - Continued
|
15b. 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.
$
154
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).
Copayment paid by
enrollee for hospital
admission
152
.00
,
1
Per day
2
Per stay
AND/OR
153
Coinsurance
paid by enrollee
%
Report for an admission at an "in-network"/participating
hospital (if applicable).
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
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.
218
1
Yes - Continue with Question 15d
2
No - SKIP to Question 16
156
.00 Copayment paid by enrollee
$
for office visit
AND/OR
157
% Coinsurance
Some plans may have both a dollar copayment and a
percentage coinsurance.
paid by enrollee
Report for an "in-network"/participating general
practitioner during normal office hours.
673
health plan?
1
Yes - Continue with Question 17
2
No
Don’t know
3
Report for the least expensive pharmacy available to
the enrollee under the plan, excluding any mail-order
programs.
SKIP to Question 18a
Lowest cost to enrollee
17. How much and/or what percentage did an
enrollee pay out-of-pocket for the lowest tier
of prescription drug coverage?
}
655
$
.00
Copayment
AND/OR
677
%
Coinsurance
Include all copayments, coinsurance and deductibles.
29043064
18a. What was the MAXIMUM ANNUAL out-of-pocket
161
$
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
,
.00
OR
163
No individual maximum
162
$
expense for a family of four?
,
.00
OR
222
No family maximum
Continue with Page 7, Question 19
FORM MEPS-11(S) (01-24-2013)
§>%?a¤
16. Were prescription drugs covered under this
7
PLAN CHARACTERISTICS
19. Could this plan have refused to cover persons
183
with pre-existing medical or health conditions?
20. Did this plan have a policy requiring a
1
Yes
2
No
1
Yes
2
No
185
waiting period before covering pre-existing
conditions?
21. Which of the services listed were covered by
this plan?
22. Was this a grandfathered health plan as defined
by the Affordable Care Act?
See the definition sheet included with this package for an
explanation.
173
Chiropractic care . . . . . . . . . . . .
736
Routine vision care for children .
587
Routine vision care for adults . .
737
Routine dental care for children .
176
Routine dental care for adults . .
738
Mental health care . . . . . . . . . . .
182
Substance abuse treatment . . . .
739
1
Yes
2
No
3
Don’t know
Yes
No
Don’t
know
(1)
(2)
(3)
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.
29043072
If this is your last health insurance plan, please continue with the form MEPS-11(R),
Section C.
FORM MEPS-11(S) (01-24-2013)
§>%?i¤
*** PLEASE NOTE ***
OMB No. 0935-0110: Approval Expires 12/31/2014
Section B – GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
Answer Questions 1-16 for each plan
offered. Begin with the plan having the largest enrollment and proceed through to the
plan with the smallest enrollment of ACTIVE
employees. Report for a typical pay
period in 2013.
100
012
FOR CENSUS USE ONLY
100
Name of plan
012
Name of plan
2013 ENROLLMENTS
1a.
b.
Total ACTIVE employees ENROLLED
in plan
125
ACTIVE employees ENROLLED in
SINGLE coverage
129
125
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)
2013 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
29073012
4a.
,
b.
c.
d.
570
,
Employee contribution for
employee-plus-one premium
637
Total employee-plus-one
premium
FORM MEPS-11C(S) (02-13-2013) Draft 6
$
.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
§>(?-¤
3a.
2
Section B – GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
2013 PREMIUMS - Continued
5a. Family Coverage
b. Government/Employer contribution for
137
135
,
$
$
.00
,
134
.00
,
134
$
133
Mark (X) ONLY one.
.00
,
136
$
d. Total family premium
The amounts reported in the
premium questions are based
on which of the following time
periods?
Not offered - Skip to Question 6
2
.00
136
premium
6.
137
135
$
family premium
c. Employee contribution for family
Not offered - Skip to Question 6
2
$
.00
,
1
Weekly
5
Quarterly
2
Every 2
weeks
4
Yearly
3
Monthly
1
Coverage was underwritten
by an insurer - Skip to
Question 9
2
133
.00
,
1
Weekly
5
Quarterly
2
Every 2
weeks
4
Yearly
3
Monthly
1
Coverage was underwritten
by an insurer - Skip to
Question 9
Plan was self-insured Continue with Question 8a
2
Plan was self-insured Continue with Question 8a
3
Don’t know - Skip to
Question 9
3
Don’t know - Skip to
Question 9
1
Yes - Used TPA or ASO
1
Yes - Used TPA or ASO
2
No - Self-administered the plan
2
No - Self-administered the plan
1
Yes - Continue with
Question 8c
1
Yes - Continue with
Question 8c
2
No - Skip to Question 9
2
No - Skip to Question 9
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).
29073020
8a.
Complete Questions 8a-c if this plan
was self-insured.
Did your government unit
employ a third party
administrator (TPA) or purchase
administrative services only
(ASO) from an insurer for this
self-insured plan?
b. Did your government unit
713
107
purchase stop-loss coverage for
this plan?
c. What was the specific stop-loss
amount per employee?
FORM MEPS-11C(S) (02-13-2013)
105
713
107
732
732
$
,
,
.00
$
,
,
.00
§>(?5¤
SELF-INSURED PLAN INFORMATION
3
Section B – GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
PLAN INFORMATION
9. 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
183
cover persons with pre-existing
medical or health conditions?
11. Did this plan have a policy
1
Yes
2
No
1
Yes
2
No
185
requiring a waiting period
before covering pre-existing
conditions?
12. Did the PREMIUMS for this plan
vary by any of these employee
characteristics?
Mark (X) all that apply.
183
29073038
Mark (X) all that apply.
No
1
Yes
2
No
Age
138
Age
139
Gender
139
Gender
141
Wage or salary levels
141
Wage or salary levels
733
Smoker/Non-smoker status
733
Smoker/Non-smoker status
142
Other
142
Other
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 levels
643
Wage or salary levels
644
Occupation
644
Occupation
706
Length of employment
706
Length of employment
734
Participation in a
fitness/weight loss program
734
Participation in a
fitness/weight loss program
735
Participation in a smoking
cessation program
735
Participation in a smoking
cessation program
645
Other
645
Other
OR
OR
646
FORM MEPS-11C(S) (02-13-2013)
2
138
13. Did the amount an EMPLOYEE
Do not include internal incentive
programs that do not impact
contributions.
Yes
185
OR
CONTRIBUTED toward his/her
own coverage vary by any of
these employee characteristics?
1
Employee contribution did
not vary
646
Employee contribution did
not vary
§>(?G¤
10. Could this plan have refused to
Month
4
GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
PLAN INFORMATION - Continued
14. Was this a grandfathered health
739
plan as defined by the
Affordable Care Act?
739
1
Yes
No
2
No
Don’t know
3
Don’t know
1
Yes, contributed to an HSA
1
Yes
2
3
HEALTH SAVINGS ACCOUNT (HSA)
15. If the deductibles for this plan
were $1,250 or higher for single
coverage and $2,500 or higher
for family coverage, did your
government unit contribute to a
Health Savings Account (HSA)
for the plan enrollees in 2013?
714
714
1
Yes, contributed to an HSA
2
No, did not contribute to an
HSA
2
No, did not contribute to an
HSA
4
Don’t know
4
Don’t know
*** PLEASE NOTE ***
Complete a MEPS-11C(S) column for each plan that was offered.
29073046
REMEMBER TO ENCLOSE A COPY OF EACH PLAN BROCHURE OR PROVIDE THE BROCHURE
WEBSITE ADDRESS WITH YOUR CONTACT INFORMATION ON THE MEPS-11C(F). PLEASE PROVIDE
THE GENERAL USER INFORMATION IN THE REMARKS SECTION.
If you have any questions concerning this survey, please call 1-888-206-5068.
FORM MEPS-11C(S) (02-13-2013)
§>(?O¤
If you have completed your last health insurance plan, continue
with form MEPS-11C(R), Section C.
OMB No. 0935-0110: Approval Expires 12/31/2014
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: 2013 Health Insurance Cost Study (critical items for 2013 plan year)
Thank you for agreeing to complete the following summary charts for the 2013 plan year.
Please note:
EE = EMPLOYEE-paid portion of the monthly premium.
TOT = TOTAL monthly premium (Census will calculate employer portion.)
ENROLLMENT
2013 Active Employees
Single
Coverage
Plan
Name(s)
1)
Was this plan self-insured?
No
Was this plan self-insured?
No
§>3?4¤
Was this plan self-insured?
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. Please do not mail questionnaires to this address as it will delay data processing. If the enclosed envelope
has been misplaced, please use address on front page of form to return questionnaire.
FORM MEPS-GRID (12-05-2012) Draft 1
29183019
Yes
Estimates are acceptable.
To:
Government:
ID:
From:
U.S. Census Bureau
Toll Free: (888) 206-5068
ENROLLMENT
2013 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?<¤
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 2013 medical plans when returning this grid. Thank you.
FORM MEPS-GRID (12-05-2012)
29183027
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
2013 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?D¤
2. In 2013, did you offer any of the following fringe benefits?
Paid Vacation
Yes
No
Paid Sick Leave
Yes
No
Life Insurance
Yes
No
Disability Insurance
Yes
No
Retirement/Pension plans
Yes
No
Yes
No
Flexible Spending Account
Yes
No
Dental
Yes
No
Vision
Yes
No
Prescription Drugs
Yes
No
Long-term Care
Yes
No
3. In 2013, did you offer any of these tax-advantaged benefits? Pre-tax contribution for Health Insurance
4. In 2013, did you offer any of these optional coverage
services to active employees at a premium SEPARATE
from the comprehensive health plan premium?
5. What was the total amount paid for optional coverage for all ACTIVE employees during a TYPICAL
MONTH at this government unit in 2013? (Include both employer and employee contributions.)
$
29183035
1. How many hours per week must an employee work to be eligible for health insurance?
.00
Please include a comparison chart or summary of benefits for all 2013 medical plans when returning this grid. Thank you.
FORM MEPS-GRID (12-05-2012)
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
2013 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2013 AT
YOUR COMPANY.
Please use photocopies of this MEPS-15(S) form if sufficient copies were not included in this reporting
package.
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 2013, 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.
29103017
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-15(S) (01-28-2013) Draft 8
§>+?2¤
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-c if this plan was self-insured.
6a. Did your organization employ a third party
713
administrator (TPA) or purchase administrative
services only (ASO) from an insurer for this
self-insured plan?
b. Did your organization purchase stop-loss
Yes - Used a TPA or ASO
2
No - Self-administered the plan
1
Yes - Continue with Question 6c
2
No - SKIP to Question 7a
107
coverage for this plan?
c. What was the specific stop-loss amount per
1
732
$
employee?
,
,
.00
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
7a. How many ACTIVE employees at this location
125
were ENROLLED in this plan during a typical
pay period in 2013?
Active employees enrolled
in plan
Include full-time, part-time, temporary and seasonal
employees.
Exclude former employees, leased or contract workers
and retirees.
129
29103025
ENROLLED in SINGLE coverage during a
typical pay period in 2013?
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 2013?
571
Active employees enrolled
in single coverage
Active employees enrolled
in employee-plus-one
coverage
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 2013?
705
Active employees enrolled
in family coverage
Continue with Page 3, Question 8
FORM MEPS-15(S) (01-28-2013)
§>+?:¤
b. How many of these ACTIVE employees were
3
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 2013?
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 2013.
Include any employer contributions to an HSA 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
.00 Total single
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.
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?
29103033
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?
636
$
637
$
,
Employee
contribution for
.00 employee-plus-one
premium
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
Mark (X) only one.
FORM MEPS-15(S) (01-28-2013)
,
Employer
contribution for
.00 employee-plus-one
premium
§>+?B¤
EMPLOYEE-PLUS-ONE 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
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 Total family
premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Mark (X) only one.
12a. Did the PREMIUMS for this insurance plan
vary by any of these characteristics?
138
Age. . . . . . . . . . . . . . . . . . . . .
139
Gender . . . . . . . . . . . . . . . . . .
141
Wage or salary levels . . . . . . .
733
Smoker/Non-smoker status . . .
142
Other. . . . . . . . . . . . . . . . . . . .
b. Did the amount an EMPLOYEE CONTRIBUTED
toward his/her own coverage vary by any of
these employee characteristics?
29103041
Do not include internal incentive programs that do not
impact contributions.
FORM MEPS-15(S) (01-28-2013)
641
Hours worked . . . . . . . . . . . . .
642
Union status . . . . . . . . . . . . . .
643
Wage or salary levels . . . . . . .
644
Occupation . . . . . . . . . . . . . . .
706
Length of employment. . . . . . .
734
Participation in a fitness/weight
loss program . . . . . . . . . . . . . .
735
Participation in a smoking
cessation program. . . . . . . . . .
645
Other. . . . . . . . . . . . . . . . . . . .
Yes
(1)
No
(2)
Don’t
know
(3)
Yes
(1)
No
(2)
Don’t
know
(3)
§>+?J¤
GENERAL PREMIUM INFORMATION
5
INDIVIDUAL DEDUCTIBLES
13a. Did this plan have a deductible?
151
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.
b. What was the annual deductible an individual
1
Yes - Continue with Question 13b
2
No - SKIP to Question 16a
146
$
paid?
Report "IN-NETWORK" deductibles (if applicable).
.00 Individual annual
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
Question 16b on Page 6.
,
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
$
Report for a family of four.
,
.00 Total annual family
deductible
15.
If the deductibles you reported in Questions
13 and 14 were $1,250 or higher for single
coverage and $2,500 or higher for family
coverage, did your organization contribute
to a Health Savings Account (HSA) for the
plan enrollees in 2013?
714
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA
4
Don’t know
29103058
PAYMENTS
16a. Was hospital care covered under this plan?
FORM MEPS-15(S) (01-28-2013)
155
1
Yes - Continue with Question 16b on Page 6
2
No - SKIP to Page 6, Question 16c
§>+?[¤
HEALTH SAVINGS ACCOUNT (HSA)
6
PAYMENTS - Continued
16b. 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.
$
154
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).
Copayment paid by
enrollee for hospital
admission
152
.00
,
1
Per day
2
Per stay
AND/OR
153
Coinsurance
paid by enrollee
%
Report for an admission at an "in-network"/participating
hospital (if applicable).
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
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.
Were prescription drugs covered under this
health plan?
673
1
Yes - Continue with Question 18
2
No
Don’t know
3
18.
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 19a
Lowest cost to enrollee
655
$
.00
Copayment
AND/OR
677
%
Coinsurance
29103066
Include all copayments, coinsurance and deductibles.
19a. What was the MAXIMUM ANNUAL
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?
,
.00
OR
222
No family maximum
Continue with Page 7, Question 20
FORM MEPS-15(S) (01-28-2013)
§>+?c¤
17.
7
PLAN CHARACTERISTICS
20. Could this plan have refused to cover persons
183
with pre-existing medical or health conditions?
21. Did this plan have a policy requiring a
1
Yes
2
No
1
Yes
2
No
185
waiting period before covering pre-existing
conditions?
22. Which of the services listed were covered by
Yes
(1)
this plan?
23. Was this a grandfathered health plan as defined
by the Affordable Care Act?
See the definition sheet included with this package for an
explanation.
173
Chiropractic care . . . . . . . . . . . .
736
Routine vision care for children .
587
Routine vision care for adults . .
737
Routine dental care for children .
176
Routine dental care for adults . .
738
Mental health care . . . . . . . . . . .
182
Substance abuse treatment . . . .
739
1
Yes
2
No
3
Don’t know
No
(2)
Don’t
know
(3)
29103074
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) (01-28-2013)
§>+?k¤
*** PLEASE NOTE ***
| File Type | application/pdf |
| File Modified | 2013-08-29 |
| File Created | 2013-08-29 |