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pdfOMB No. 0935-0110: Approval Expires 11/30/2016
2015 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 (03-26-2015)
§>"S.¤
29015013
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 2015.
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
or visit: econhelp.census.gov/meps
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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29015021
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 2015?
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 2015 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 2014, did your organization make available or
contribute to the cost of any health insurance
plans for its ACTIVE employees at this location?
741
1
Yes – Offered
2
No – Not offered
3
Don’t know
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1.
Continue with Page 4, Section C
FORM MEPS-10
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 2015?
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 2015?
b. How many of these employees were ELIGIBLE
If your organization did not offer health
insurance in 2015, 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 2015, 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 2015, 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
29015047
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 2015, 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
5
Section C – EMPLOYMENT CHARACTERISTICS - Continued
Provide information for a TYPICAL pay period in 2015.
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 2015,
approximately what percentage earned –
Less than $11.50 per hour? . . . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
Between $11.50 and $28.00 per hour?. . . . . . . . . .
Approximately $24,000 to $58,000 a year
More than $28.00 per hour? . . . . . . . . . . . . . . . . . . .
Approximately $58,000 a year or more
8.
For the employees at this location in 2015,
approximately how many earned more than
$43.50 per hour?
Approximately $90,000 a year or more
022
%
Earned less than $11.50 per hour
023
%
Earned between $11.50 and $28.00
per hour
024
%
726
Earned more than $28.00 per hour
Number of employees that
earned more than $43.50 per hour
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If none, enter "0".
Continue with Page 6, Section D
FORM MEPS-10
6
Section D – FRINGE BENEFITS CHARACTERISTICS
1.
Did your organization offer the following fringe
benefits to its employees at this location in
2015?
If Paid Time Off (PTO) is offered, mark (X) Yes for paid
vacation AND paid sick leave.
2.
Did your organization offer any of these
tax-advantaged benefits to its employees at this
location in 2015?
Yes
(1)
050
Paid vacation . . . . . . . . . . . . . . . . .
051
Paid sick leave . . . . . . . . . . . . . . . .
052
Life insurance. . . . . . . . . . . . . . . . .
053
Disability insurance . . . . . . . . . . . . .
054
Retirement/pension plans. . . . . . . . .
Yes
(1)
627
See the definition sheet MEPS-20(D) included with this
package for an explanation of these benefits.
056
These benefits are also known as Section 125 Cafeteria
plans.
057
Don’t
No know
(2)
(3)
Don’t
No know
(2)
(3)
Employee contributions to health
insurance made on a pre-tax basis. .
Flexible SPENDING Accounts
(FSA) for healthcare. . . . . . . . . . . . .
Flexible Benefits Plans. . . . . . . . . . .
Full cafeteria plans that offer
employees a set of benefits
from which to choose.
If your organization DID make available or contribute to the cost of any health insurance
coverage to its employees in 2015, continue with Section E.
If your organization DID NOT make available or contribute to the cost of any health insurance
coverage to its employees in 2015, SKIP to Page 8, Section G.
Section E – HEALTH INSURANCE EXCHANGES
SMALL BUSINESS, 50 OR FEWER EMPLOYEES
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2.
Will your organization claim a Small Business
Health Care Tax Credit on its 2015 federal
taxes?
744
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
728
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.
SKIP to Page 7, Section F
LARGE BUSINESS, MORE THAN 50 EMPLOYEES
Complete only if your organization offered insurance and has more
than 50 employees. Otherwise, SKIP to Page 7, Section F.
3.
Did your organization offer health insurance for
active employees through a private exchange
(also known as a corporate exchange)? (See
definition sheet, MEPS-20(D))
A private exchange is one created by a consulting company,
insurance carrier, or other private organization, not by either
a federal or state government. Private exchanges often allow
employees to choose from several health insurance options
offered on the exchange.
FORM MEPS-10
765
1
Yes
2
No
3
Don’t know
Continue with Page 7, Section F
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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 sheet, MEPS-20(D)).
Otherwise, SKIP to Question 3.
1. Did your organization offer health insurance
through a Small Business Health Options
Program (SHOP) exchange or marketplace in
your state?
7
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 2015 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 2015?
$
3.
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4.
5.
For 2015, 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?
,
.00
Monthly optional coverage cost
Include both employer and employee contributions.
2.
,
197
723
745
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
5
All spouses eligible, greater employee
contribution if spouse eligible through own
employer.
6
All spouses eligible, same contribution.
7
All spouses eligible, don’t know contribution.
2
Limited spouses eligible, only if not offered
by own employer.
3
No spouses eligible.
4
Don’t know
Did your organization offer health insurance
coverage to UNMARRIED domestic partners?
Yes
(1)
730
Same sex domestic partners . . . . . .
731
Opposite sex domestic partners . . . .
Don’t
No know
(2)
(3)
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 MEPS-20(D) included with this package for an
explanation of these terms.
1.
Did your organization provide health insurance
coverage to any person who retired in 2015 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.
628
1
Yes – Continue with Question 3b
2
No
3a. Were any of the enrolled retirees, reported in
Question 2, under 65 years of age?
Don’t Know
3
b. In a typical month, how many retirees under 65
Number of retirees under 65
enrolled in health insurance
573
%
ENROLLED in SINGLE coverage?
d. For a typical plan in 2015, how much did the
$
$
.00
Employer contribution for
single premium
,
.00
Total single premium
576
$
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
29015088
,
575
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2015, how much did the
Retirees under 65 enrolled in
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
SKIP to Page 9, Question 4a
572
years of age were enrolled in health insurance
through your organization at all of its locations?
c. What percentage of these retirees were
}
,
.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
premium for this typical retiree with FAMILY
coverage?
577
$
,
.00
Total family premium
Continue with Page 9, Question 4a
FORM MEPS-10
§>"Sy¤
If this was a self-insured plan, report the premium
equivalent.
9
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
3
Don’t Know
Question 2, 65 years of age or over?
b. In a typical month, how many retirees 65 years
Number of retirees 65 or over
enrolled in health insurance
579
%
ENROLLED in SINGLE coverage?
d. For a typical plan in 2015, how much did the
$
.00
,
Employer contribution for
single premium
581
$
premium for this typical retiree with SINGLE
coverage?
f. For a typical plan in 2015, how much did the
Retirees 65 or over enrolled in
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
SKIP to Question 5a
578
of age or over were enrolled in health insurance
through your organization at all of its locations?
c. What percentage of these retirees were
}
.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?
$
.00
,
Total family premium
For Questions 5a through 5c, NEW RETIREES refers only to
persons who retired from your organization in 2015.
630
Exclude any retirees that have coverage through COBRA or
state continuation-of-benefits laws.
5a. Did your organization offer health insurance to
29015096
any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
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
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 ***
29015104
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
Telephone number
–
220
Extension
216
Fax
–
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-10
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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).
| File Type | application/pdf |
| File Modified | 2015-08-26 |
| File Created | 2015-03-17 |