Form #3 Form #3 Plan Questionnaire

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

2014 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2014 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 2014, 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.

29024015

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) (03-05-2014)

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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

1

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

732

$

employee?

,

,

.00

PLAN LEVEL
746

7a. Health insurance plans are classified into
different "metal" levels or tiers based on their
level of benefits and cost-sharing provisions.
Which level or tier was this plan in?

b. What was the actuarial value of this plan?

29024023

Actuarial value – the percentage of medical
expenses paid by the plan rather than out-of-pocket
by a typical group of enrollees.

1

Bronze

2

Silver

3

Gold

4

Platinum

5

Don’t know

SKIP to Question 8a

747

%
748

Don’t know

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.

8a. How many ACTIVE employees at this location
were ENROLLED in this plan during a typical
pay period in 2014?

125

Active employees enrolled
in plan

Include full-time, part-time, temporary and seasonal
employees.
Exclude former employees, leased or contract workers
and retirees.
Continue with Page 3, Question 8b
FORM MEPS-10(S)

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Complete only if your organization 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 Question 7b.

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ACTIVE ENROLLMENT – Continued
8b. How many of these ACTIVE employees were

129

Active employees enrolled
in single coverage

ENROLLED in SINGLE coverage during a
typical pay period in 2014?

c.

EMPLOYEE-PLUS-ONE coverage is health insurance
coverage for an employee-plus-spouse or an
employee-plus-child AT A LOWER PREMIUM than
family coverage.
If your organization offered EMPLOYEE-PLUSONE coverage, how many ACTIVE employees
were ENROLLED during a typical pay period in
2014?

Active employees enrolled
in employee-plus-one
coverage

571

Include enrollment for both employee-plus-spouse and
employee-plus-child coverage.

d. How many ACTIVE employees were ENROLLED

705

Active employees enrolled
in family coverage

in FAMILY (not single or employee-plus-one)
coverage during a typical pay period in 2014?

COBRA ENROLLMENT
9.

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 2014?

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 2014.
If there is an HSA or HRA associated with this plan, include any employer contributions to an HSA or HRA account in the
employer contribution to the premium.
552

10a. 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 10b

2

No - SKIP to Page 4, Question 11a
Employer

131

$

29024031

based on which one of the following time
periods?

,

single premium
Employee

132

$

130

$

typical employee with SINGLE coverage?

e. The amounts reported in Questions 10b-d are

.00 contribution for

133

.00 contribution for

,

single premium

.00 Total single

,

premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly

Mark (X) only one.

Continue with Page 4, Question 11a
FORM MEPS-10(S)

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SINGLE COVERAGE

4

PLAN PREMIUMS - Continued
EMPLOYEE-PLUS-ONE COVERAGE
If employee-plus-one premiums were different for
employee-plus-child and employee-plus-spouse
coverages, report for employee-plus-one child. If
premiums varied for other reasons, report for a
TYPICAL employee.

570

11a. Was EMPLOYEE-PLUS-ONE coverage offered
under this plan?

b. For this plan, how much did the EMPLOYER
contribute toward the plan premium of one
typical employee with EMPLOYEE-PLUS-ONE
coverage?

c. How much did this typical EMPLOYEE with
EMPLOYEE-PLUS-ONE coverage contribute
toward his/her own premium?

d. What was the TOTAL premium for this typical
employee with EMPLOYEE-PLUS-ONE
coverage?

e. The amounts reported in Questions 11b-d are

1

Yes - Continue with Question 11b

2

No - SKIP to Question 12a

$

,

Employee
contribution for
.00 employee-plus-one
premium

637

$

,

Total

635

$
638

based on which one of the following time
periods?

.00 employee-plus-one

,

premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly

1

Yes - Continue with Question 12b

2

No - SKIP to Page 5, Question 13a

Mark (X) only one.

FAMILY COVERAGE

Employer
contribution for
.00 employee-plus-one
premium

636

137

If premium varied by family size, report for a family of four.

12a. Was FAMILY coverage offered under this plan?

Employer

135

$

contribute toward the plan premium of one
typical employee with FAMILY coverage?

c. How much did this typical EMPLOYEE with

29024049

based on which one of the following time
periods?

family premium
Employee

$

.00 contribution for

,

family premium

134

employee with FAMILY coverage?

e. The amounts reported in Questions 12b-d are

,

136

FAMILY coverage contribute toward his/her
own premium?

d. What was the TOTAL premium for this typical

.00 contribution for

$

553

.00 Total family

,

premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly

Mark (X) only one.

Continue with Page 5, Question 13a
FORM MEPS-10(S)

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b. For this plan, how much did the EMPLOYER

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GENERAL PREMIUM INFORMATION
13a. Did the TOTAL premium reported earlier for

749

SINGLE coverage vary by the age of the
employee enrolled in the plan?
Refer to Question 10d on Page 3.

b. Did the TOTAL premium reported earlier for

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

4

Family coverage not offered

752

FAMILY coverage vary depending on the
number of family members covered by the
plan?
Refer to Question 12d on Page 4.

c. Did the amount individual EMPLOYEES

Yes
(1)

contributed toward their SINGLE coverage
premium vary by any of these characteristics?
Do not include incentive programs that do not impact
contributions.

734

Participation in a fitness/weight
loss program . . . . . . . . . . . . . .

735

Participation in a smoking
cessation program. . . . . . . . . .

761

Wellness/Health monitoring . . .

750

Older employees pay more . . .

No
(2)

Don’t
know
(3)

– IF NO OR DON’T KNOW, SKIP to Question 14a

d. Why did older EMPLOYEES pay a larger

751

contribution toward their premium for
SINGLE coverage under this plan?

1

Your organization pays a fixed PERCENT of the
premium for all employees, and older workers
have higher premiums

2

Your organization pays a fixed DOLLAR amount
toward the premium for all employees, and older
workers have higher premiums

3

Other

4

Don’t know

Check only one.

14a. Did this plan have a deductible?

151

29024056

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

2

No - SKIP to Page 6, Question 17a

$

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.

DO NOT report COPAYMENTS or individual or family
out-of-pocket maximums here.

Yes - Continue with Question 14b

146

paid?

If deductible is per overnight hospital stay, it is not an
annual deductible and should be reported under
Question 17b on Page 6.

1

147

$

,

.00

Physician care

148

$

,

.00

Hospital care

Continue with Page 6, Question 15a
FORM MEPS-10(S)

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INDIVIDUAL DEDUCTIBLES

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FAMILY DEDUCTIBLES
15a. 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 15b

2

No - SKIP to Question 15c

3

Family coverage not offered - SKIP to
Question 16

150

Number of family members

149

$

.00 Total annual family

,

Report for a family of four.

deductible

HEALTH SAVINGS ACCOUNT (HSA)
16.

If the deductibles you reported in Questions
14 and 15 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 2014?

714
1

Yes, contributed to an HSA

2

No, did not contribute to an HSA

4

Don’t know

PAYMENTS

b. How much and/or what percentage of the total
bill did an enrollee pay out-of-pocket for an
inpatient hospital admission after any annual
deductible was met?
Out-of-pocket expense - Those costs paid directly
by the enrollee.

155

Yes - Continue with Question 17b

2

No - SKIP to Question 18a

152

$
154

Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).

1

.00

,

1

Per day

2

Per stay

Copayment paid by
enrollee for hospital
admission

AND/OR
153

%

Report for an admission at an "in-network"/participating
hospital (if applicable).

Coinsurance
paid by enrollee

Do not include any physician charges incurred during
the hospital admission.

29024064

18a. Was physician care covered under this plan?

FORM MEPS-10(S)

218
1

Yes - Continue with Question 18b on Page 7

2

No - SKIP to Page 7, Question 19a

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17a. Was hospital care covered under this plan?

7

PAYMENTS - Continued
18b. How much and/or what percentage of the total

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.

19a. Were prescription drugs covered under this

673

health plan?

1

Yes - Continue with Question 19b

2

No
Don’t know

3

b. How much and/or what percentage did an
enrollee pay out-of-pocket for each type of
prescription drug covered?

}

SKIP to Question 20a

Generic
753

$

.00
Copayment

AND/OR
754

%

Coinsurance

Preferred brand name
755

$

.00
Copayment

AND/OR
756

%

Coinsurance

Non-preferred brand name
757

$

.00
Copayment

AND/OR
758

%

Coinsurance

20a. What was the MAXIMUM ANNUAL

161

29024072

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 8, Question 21
FORM MEPS-10(S)

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Include all copayments, coinsurance and deductibles.

8

PLAN CHARACTERISTICS
21. Which of the services listed were covered by

Yes
(1)

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

No
(2)

Don’t
know
(3)

*** PLEASE NOTE ***
If your organization offered only one health insurance plan,
you have completed your response to this survey.

29024080

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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)