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

2015 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2015 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.

For 2015, what was the name of the health
insurance plan with the largest (or next
largest) enrollment of ACTIVE employees?
Examples:

2.

Which type of health care provider arrangement
was available through this plan?

29025012

103
1

Exclusive providers
(Examples: Most HMO, IPA, and EPO plans)

Any providers - Enrollees may go to providers of their
choice with no cost incentives to use a particular group of
providers.

2

Any providers
(Examples: Most fee-for-service plans)

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

Mixture of preferred and any providers
(Examples: Most PPO and POS plans)

1

Yes

2

No

3

Don’t know

1

Union

2

Trade association

3

Neither

Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order
to be referred to a specialist?

104

For plans with multiple options, answer for the "in-network"
option.

4.

Name of plan

• Blue Cross Blue Shield, High Option
• Company Plan A
• Aetna HMO

Exclusive providers - Enrollees must go to providers
associated with the plan for all non-emergency care in
order for the costs to be covered.

3.

012

Was this plan offered through a union or a trade
association?

113

Continue with Page 2, Question 5
FORM MEPS-10(S) (03-17-2015) Draft 6

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1.

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 7

2

Self-insured - Continue with Question 6a

3

Don’t know - SKIP to Question 7

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 7

107

coverage for this plan?

c. What was the specific stop-loss amount per

732

$

employee?

,

.00

,

PLAN LEVEL
SMALL BUSINESS, 50 OR FEWER EMPLOYEES
Complete only if your organization 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 8.

7.

746

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?

1

Bronze

4

Platinum

2

Silver

5

Don’t know

3

Gold

6

N/A, Grandfathered Plan
SKIP to Question 9a

LARGE BUSINESS, MORE THAN 50 EMPLOYEES
What was the actuarial value of this plan?

29025020

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

747

%
748

Don’t know

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.

9a. How many ACTIVE employees at this location
were ENROLLED in this plan during a typical
pay period in 2015?

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 9b
FORM MEPS-10(S)

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8.

3

ACTIVE ENROLLMENT – Continued
9b. How many of these ACTIVE employees were
ENROLLED in SINGLE coverage during a
typical pay period in 2015?

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
2015?

129

Active employees enrolled
in single coverage

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 2015?

COBRA ENROLLMENT
10.

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 2015?

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 2015.
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
1

Yes - Continue with Question 11b

2

No - SKIP to Page 4, Question 12a

11a. 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

Employer

131

$

are based on which one of the following time
periods?
Mark (X) only one.

29025038

single premium
Employee

$

.00 contribution for

,

single premium

130

typical employee with SINGLE coverage?

e. The amounts reported in Questions 11b-d

,

132

SINGLE coverage contribute toward his/her
own premium?

d. What was the TOTAL premium for this

.00 contribution for

$

133

.00 Total single

,

premium

1

Weekly

5

Quarterly

2

Every 2 weeks

4

Yearly

3

Monthly

Continue with Page 4, Question 12a
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

12a. 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

1

Yes - Continue with Question 12b

2

No - SKIP to Question 13a

$

,

Employee
contribution for
.00 employee-plus-one
premium

637

$

,

Total

635

employee with EMPLOYEE-PLUS-ONE
coverage?

e. The amounts reported in Questions 12b-d

Employer
contribution for
.00 employee-plus-one
premium

636

$
638

are 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 13b

2

No - SKIP to Page 5, Question 14a

Mark (X) only one.
FAMILY COVERAGE
137

13a. 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

$

29025046

are 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 13b-d

,

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 14a
FORM MEPS-10(S)

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

5

GENERAL PREMIUM INFORMATION
14a. Did the TOTAL premium reported earlier for

749

SINGLE coverage vary by the age of the
employee enrolled in the plan?

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

4

Family coverage not offered

Refer to Question 11d on Page 3.

b. Did the TOTAL premium reported earlier for

752

FAMILY coverage vary depending on the
number of family members covered by the
plan?
Refer to Question 13d on Page 4.

c. Did the amount individual EMPLOYEES
contributed toward their SINGLE coverage
premium vary by any of these characteristics?
Do not include incentive programs that do not impact
contributions.

d. Did older EMPLOYEES contribute more

Yes
(1)
734

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

735

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

761

Wellness/Health monitoring. . . . . . . . .

750

toward their SINGLE coverage premium?

e. Why did older EMPLOYEES contribute more

Don’t
know
(3)

1

Yes

2

No

3

Don’t know

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

751

toward their SINGLE coverage premium?

No
(2)

Check only one.

}

IF NO OR DON’T KNOW,
SKIP to Question 15a

15a. Did this plan have a deductible?

151

29025053

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

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

2

No - SKIP to Page 6, Question 18

$

Report "IN-NETWORK" deductibles (if applicable).

If deductible is per overnight hospital stay, it is not an
annual deductible and should be reported under
Question 19b on Page 6.

Yes - Continue with Question 15b

146

paid?

If separate deductibles apply, enter physician care and
hospital care amounts in appropriate boxes.

1

,

.00 Individual annual
deductible

OR
Separate deductibles for:
147

$

,

.00

$

,

.00

Physician care

148

Hospital care

Continue with Page 6, Question 16a
FORM MEPS-10(S)

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INDIVIDUAL DEDUCTIBLES

6

FAMILY DEDUCTIBLES
16a. 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

1

Yes - Continue with Question 16b

2

No - SKIP to Question 16c

3

Family coverage not offered - SKIP to
Question 17

150

Number of family members

149

paid?

$

.00

,

Report for a family of four.

Total annual family
deductible

HEALTH SAVINGS ACCOUNT (HSA)
17.

If the deductibles you reported in Questions
15 and 16 were $1,300 or higher for single
coverage and $2,600 or higher for family
coverage, did your organization contribute
to a Health Savings Account (HSA) for the
plan enrollees in 2015?

714
1

Yes, contributed to an HSA

2

No, did not contribute to an HSA

4

Don’t know

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
18.

An employer can offer a Health
Reimbursement Arrangement (HRA) by setting
up an account to reimburse employees for
medical expenses not covered by health
insurance. Did your organization offer an HRA
associated with this plan in 2015?

710
1

Yes

2

No

3

Don’t know

HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs). See definition sheet
MEPS-20(D) for more information.

19a. Was hospital care covered under this plan?

29025061

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.
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for precertified hospital admissions (if applicable).
Report for an admission at an "in-network"/participating
hospital (if applicable).

155
1

Yes - Continue with Question 19b

2

No - SKIP to Page 7, Question 20a

152

$
154

.00

,

1

Per day

2

Per stay

Copayment paid by
enrollee for hospital
admission

AND/OR
153

%

Coinsurance
paid by enrollee

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

Continue with Page 7, Question 20a
FORM MEPS-10(S)

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PAYMENTS

7

PAYMENTS - Continued
20a. Was physician care covered under this plan?

b. 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 - Costs paid directly by
the enrollee.

218

1

Yes - Continue with Question 20b

2

No - SKIP to Question 21a

156

$

.00

Copayment paid by enrollee
for office visit

AND/OR
157

%

Some plans may have both a dollar copayment and a
percentage coinsurance.

Coinsurance
paid by enrollee

Report for an "in-network"/participating general
practitioner, excluding preventive care visits.

21a. Were prescription drugs covered under this

673

health plan?

b. How much and/or what percentage did an
enrollee pay out-of-pocket for each type of
prescription drug covered?
Out of pocket expense - Costs paid directly by
the enrollee.

1

Yes - Continue with Question 21b

2

No

3

Don’t know

}

SKIP to Page 8, Question 22a

Generic
753

$

.00

Copayment

AND/OR
754

Some plans may have both a dollar copayment and a
percentage coinsurance.

%
762

Coinsurance

Generic not covered

Preferred brand name
755

$

.00

Copayment

AND/OR
756

%
763

Coinsurance

Preferred brand name not covered

Non-preferred brand name

$

.00

Copayment

AND/OR
758

29025079

%
764

Specialty drugs are prescription medications that
are used to treat complex, chronic and often costly
conditions.

Coinsurance

Non-preferred brand name not covered

Specialty
767

$

.00

Copayment

AND/OR

(See definition sheet MEPS-20(D) for more information).
768

%
769

Coinsurance

Specialty not covered
Continue with Page 8, Question 22a

FORM MEPS-10(S)

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757

8

PAYMENTS - Continued
Include all copayments, coinsurance and deductibles.
161

22a. What was the MAXIMUM ANNUAL

$

out-of-pocket expense for an individual?
Out-of-pocket expense - Those costs paid directly
by the enrollee.

.00

OR
163

No individual maximum

This is often referred to as a catastrophic limit.

b. What was the MAXIMUM ANNUAL

,

162

$

out-of-pocket expense for a family of four?

,

.00

OR
222

No family maximum

PLAN CHARACTERISTICS

24.

Which of the services listed were covered by
this plan?

Was this a grandfathered health plan as defined
by the Affordable Care Act?
See the definition sheet MEPS-20(D) included with this
package for an explanation.

Yes
(1)
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

29025087

*** PLEASE NOTE ***
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)

Don’t
No know
(2)

(3)

§>#Sx¤

23.