Form #2 Form #2 Establishment Questionnaire

OMB No. 0935-0110: Approval Expires 11/30/2016

2014 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 (03-05-2014)

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29014016

INTERNET RESPONSE
You may respond to this survey via the Internet at the following secure web address:
econhelp.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 2014.
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 5220, 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

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29014024

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.

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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 2014?

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 2014 plan year?

003

Health insurance plan choices at this location

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 – PRIOR YEAR OFFERING
In 2013, did your organization offer health
insurance as a benefit to its ACTIVE employees
at this location?

741
1

Yes – Offered

2

No – Did not offer

3

Don’t know

29014032

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1.

Continue with Page 4, Section C
FORM MEPS-10

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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 2014?

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 2014?

b. How many of these employees were ELIGIBLE

If your organization did not offer health
insurance in 2014, 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 2014, how

Enrolled employees
203

many of the employees reported in Question 2a
worked part-time?

Part-time employees
If your organization did not offer health
insurance in 2014, SKIP to Question 4
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.

How many of the employees reported in
Question 2a worked less than 30 hours per
week?

Enrolled part-time employees

742

Employees worked less than
30 hours

743

29014040

5.

Is the information you provided in Questions 2, 3
and 4 above for the location listed on the cover
sheet OR did you provide information for
multiple locations?

No employees worked less than 30 hours

550
1

Information for specified location

2

Information for multiple locations

If your organization did not offer health
insurance in 2014, SKIP to Page 5, Question 7a

6.

If your organization offered health insurance,
what was the minimum number of hours per
week that an employee had to 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 7a
FORM MEPS-10

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b. How many of these part-time employees were

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Section C – EMPLOYMENT CHARACTERISTICS - Continued

Provide information for a TYPICAL pay period in 2014.
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 2014,
approximately what percentage earned –
Less than $11.50 per hour? . . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
Between $11.50 and $27.50 per hour? . . . . . . . . . .
Approximately $24,000 to $57,000 a year
More than $27.50 per hour? . . . . . . . . . . . . . . . . . . .
Approximately $57,000 a year or more

For the employees at this location in 2014,
approximately how many earned more than
$42.50 per hour?
Approximately $88,000 a year or more

%

Earned less than $11.50 per hour

023

%

Earned between $11.50 and $27.50
per hour

024

%

726

Earned more than $27.50 per hour

Number of employees that
earned more than $42.50 per hour

29014057

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8.

022

Continue with Page 6, Section D
FORM MEPS-10

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Section D – FRINGE BENEFITS CHARACTERISTICS
1.

2.

Did your organization offer the following fringe
benefits to its employees at this location in
2014?
050

Paid vacation . . . . . . . . . . . . . . . . .

051

Paid sick leave . . . . . . . . . . . . . . .

052

Life insurance . . . . . . . . . . . . . . . .

053

Disability insurance . . . . . . . . . . . .

054

Retirement/pension plans . . . . . . . .

Did your organization offer any of these
tax-advantaged benefits to its employees at this
location in 2014?
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.

If your organization DID offer health insurance coverage to its
employees in 2014, continue with Section E.
If your organization DID NOT offer health insurance coverage to
its employees in 2014, SKIP to Page 8, Section G.

29014065

Complete only if your organization offered insurance and
has 50 employees or fewer OR has 50 full-time equivalent
employees or fewer at all locations (see definition MEPS
20-D). Otherwise, SKIP to Page 7, Section F.

1.

2.

744

Did your organization offer health insurance
through a Small Business Health Options
Program (SHOP) exchange or marketplace in
your state?
Will your organization claim a Small Business
Health Care Tax Credit on its 2014 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.

FORM MEPS-10

728

1

Yes

2

No – SKIP to Page 7, Section F

3

Don’t know – SKIP to Page 7, Section F

1

Yes

2

No

3

Organization not eligible

4

Don’t know

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Section E – SMALL BUSINESS

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Section F – 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 2014 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 2014?

$

3.

4.

For 2014, 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?

Were employees’ SPOUSES eligible for health
insurance coverage through your organization?

5a. Did your organization offer health insurance

197

723

745

730

29014073

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.

2.

,

731

1

Yes

2

No

1

Yes

2

No

3

Don’t know

1

All – all spouses eligible

2

Limited – Only spouses who weren’t eligible
through their own employer

3

No – no spouses eligible

4

Don’t know

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

Continue with Page 8, Section G
FORM MEPS-10

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b. What was the total amount paid for optional

8

Section G – 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 2014 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 H

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 2014, 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?
29014081

Employer contribution for
single premium

575

premium for this typical retiree with SINGLE
coverage?

f. For a typical plan in 2014, 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

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b. In a typical month, how many retirees under 65

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Section G – 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 2014, 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 2014, 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 2014.

630

Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.

5a. Did your organization offer health insurance to
29014099

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 H

Continue with Page 10, Section H
FORM MEPS-10

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NEW RETIREES

10
500 Remarks

Section H – PERSON COMPLETING THIS QUESTIONNAIRE

*** PLEASE NOTE ***

29014107

If your organization DID NOT offer health insurance, please complete
Section H 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

Extension

216

Fax

–
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

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If your organization offered health insurance, please complete Section H
and an attached MEPS-10(S), Plan Information Questionnaire, for each
plan offered (up to four plans).