Meps-11

OMB No. 0935-0110: Approval Expires 11/30/2018

2016 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY
Government Questionnaire

(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

29186012

INTERNET RESPONSE
You may respond to this survey via the Internet at the
following secure web address:
econhelp.census.gov/mepsgov
Your Survey Key to access the Internet form is:

If completing paper form, please RETURN TO:
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001 OR Fax to 1-800-447-4613
PLEASE RETURN ENTIRE CONTENTS OF THIS PACKAGE WITHIN

PLEASE DO NOT REMOVE THIS COVER SHEET
FORM MEPS-11 (05-19-2016)

§>3]-¤

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

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INSTRUCTIONS
1. Please report for the government unit identified on the cover sheet,
unless otherwise specified.
2. Please report data for the year 2016.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the MEPS-20(D) Health
Insurance Cost Study 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.

We are conducting this study under the authority of Section 913 of the Public Health Service Act (Title
42, United States Code (U.S.C.), Section 299b-2). Sections 924c and 308d of that Act (42 U.S.C.
Section 299c-3(c) and 42 U.S.C. Section 242m, respectively) ensure that the information you report
will be released only to authorized staff of the Census Bureau, the Agency for Healthcare Research
and Quality, and their authorized researchers and contractors.

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, 5600
Fishers Lane, Mailstop 07W41A, Rockville, MD 20857. 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-11

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29186020

7. If you have any questions or need assistance in completing the
questionnaire, please call 1-888-273-3878 or visit:
econhelp.census.gov/mepsgov

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Section A – NUMBER OF PLANS
Respond for ACTIVE employees only.

1.

Did your government unit make available or
contribute to the cost of any health insurance
plans for its ACTIVE employees in 2016?

001

For this survey, a health insurance plan is defined as a
plan where hospital and/or physician coverage is made
available to employees.

2.

How many different health insurance plan
choices did your government unit make
available or contribute to for its ACTIVE
employees during the 2016 plan year?

1

Yes - Continue with Question 2

2

No - SKIP to Question 3

003

Number of Health Plans offered

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.

PRIOR YEAR OFFERING
3.

In 2015, did your government unit make
available or contribute to the cost of any
health insurance plans for ACTIVE employees?

760
1

Yes – Offered

2

No – Not offered

3

Don’t know

Section B – EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility,
and enrollment figures.
Include full-time, part-time, temporary, and seasonal
employees.
Exclude former employees, leased or contract workers
and retirees.
740

government unit’s payroll for a TYPICAL pay
period in 2016?

All employees
If your government did not offer health insurance
in 2016, SKIP to Page 4, Question 2a.

29186038

b. How many of these employees were ELIGIBLE

201

for at least one health plan through your
government unit?

c. How many of these employees were
ENROLLED in ANY health plan through your
government unit?

Eligible employees
202

Enrolled employees

Continue with Page 4, Question 2a
FORM MEPS-11

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1a. How many employees were on your

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Section B – EMPLOYMENT CHARACTERISTICS – Continued
2a. For the same TYPICAL pay period in 2016,

759

how many employees reported in Question 1a
worked part-time?

Part-time employees
If your government unit did not offer health
insurance in 2016, SKIP to Question 3.

If none, enter "0".

b. How many of these part-time employees were

204

ELIGIBLE for at least one health plan through
your government unit?

c. How many of these part-time employees were

Eligible part-time employees
205

ENROLLED in ANY health plan through your
government unit?

3.

How many of the employees reported in
Question 1a worked less than 30 hours per
week?

Enrolled part-time employees
742

743

4.

If your government unit 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

Employees worked less than
30 hours
No employees worked less than 30 hours

Minimum hours worked per week to be
eligible
No minimum number of hours required

Provide information for a TYPICAL pay
period in 2016.
Estimates are acceptable.
The following workforce characteristics are used to
group similar government units together for analytical
purposes.

018

%

5a. Approximately what percentage of the
employees at this government unit were
union members?

b. Approximately what percentage of the

729

Union members

No union members

016

employees at this government unit were
women?

%

Women employees

%

Employees 50 years old or older

%

Earned less than $11.50 per hour

%

Earned between $11.50 and $28.50
per hour

%

Earned more than $28.50 per hour

If none, enter "0".
017

employees at this government unit were 50
years old or older?
If none, enter "0".

29186046

d. For the employees at this government unit in
2016, approximately what percentage earned –
If none, enter "0".
022

Less than $11.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $24,000 a year or less
023

Between $11.50 and $28.50 per hour? . . . . . . . .
Approximately $24,000 to $59,000 a year
024

More than $28.50 per hour? . . . . . . . . . . . . . . . . . .
Approximately $59,000 a year or more

Continue with Page 5, Question 6
FORM MEPS-11

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c. Approximately what percentage of the

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Section B – EMPLOYMENT CHARACTERISTICS – Continued
6.

For the employees at this government unit in
2016, how many earned more than $44.50 per
hour?

726

Number of employees that earned
more than $44.50 per hour

Approximately $93,000 a year or more
If none, enter "0".

Section C – FRINGE BENEFITS
CHARACTERISTICS
|
1.

Did your government unit offer the following
fringe benefits to its employees in 2016?
If Paid Time Off (PTO) is offered, mark (X) Yes for paid
vacation AND paid sick leave.

2.

Did your government unit offer any of these
tax-advantaged benefits to its employees in
2016?
See the definition sheet, MEPS-20(D), included with this
package for an explanation of these benefits.
These plans are also known as Section 125 Cafeteria
Plans.

050

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

051

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

052

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

053

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

054

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

627

Employee contributions to health
insurance made on a pre-tax basis . . .

056

Flexible SPENDING Accounts (FSA)
for healthcare . . . . . . . . . . . . . . . . . .

057

Flexible Benefits Plans. . . . . . . . . . . .
Full cafeteria plans that offer
employees a set of benefits
from which to choose.

Yes

No

Don’t
know

(1)

(2)

(3)

Yes

No

Don’t
know

(1)

(2)

(3)

Section D – HEALTH INSURANCE EXCHANGES
AND INSURANCE BROKERS
|
SMALL GOVERNMENT, 100 OR FEWER EMPLOYEES

29186053

1.

2.

744

Did your government unit offer health
insurance through a Small Business Health
Options Program (SHOP) exchange or
marketplace in your state?
Did your government unit use a third party,
such as an insurance broker or agent, to help
purchase the insurance plan(s)?

1

Yes

2

No

3

Don’t know

1

Yes

2

No

3

Don’t know

770

SKIP to Page 6, Section E

Continue with Page 6, Question 3
FORM MEPS-11

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Complete only if your government unit offered insurance
and has 100 employees or fewer OR has 100 full-time
equivalent employees or fewer at all locations (see
definition sheet, MEPS-20(D)). Otherwise, SKIP to
Page 6, Question 3.

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|

Section D – HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS – Continued
LARGE GOVERNMENT, MORE THAN 100 EMPLOYEES

Complete only if your government unit offered insurance
and has more than 100 employees. Otherwise, SKIP to
Section E.

3.

Did your government unit offer health
insurance for active employees through a
private exchange (also known as a corporate
exchange)? (See definition sheet, MEPS-20(D)).

765

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.

1

Yes

2

No

3

Don’t know

Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS
1a. Which of the listed optional coverage services,

Report single service insurance plans only.

192

Dental

193

Do not include single services covered under a
comprehensive health plan.

194

Long-term care insurance helps to cover the cost of
institutional and home care required by the chronically ill
or disabled.

195

Vision
Prescription drugs
Long-term care

562

No optional coverage - SKIP to Question 2

Mark (X) all that apply.

b. What was the total amount paid for optional

720

coverage for all ACTIVE employees during a
TYPICAL MONTH in 2016?

$

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

197

745

29186061

3.

For 2016, did your government unit impose a
waiting period before new employees could
be covered by health insurance?

4.

,

,

.00

Monthly optional coverage cost

Include both government unit and employee contributions.

2.

}

Continue with Question 1b

1

Yes

2

No

3

Don’t know

5

All spouses eligible, greater EMPLOYEE
CONTRIBUTION paid if spouses 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 government unit 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)

. . . Page 7, Section F
Continue with
FORM MEPS-11

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if any, did your government unit offer to its
ACTIVE employees in 2016 at a premium
SEPARATE from the comprehensive health
plan premium?

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Section F – RETIREE HEALTH COVERAGE CHARACTERISTICS

1.

Does your government unit or some other
government unit provide health insurance
coverage to any person who retired in 2016
OR BEFORE, or to any of their survivors?
If PHSA (COBRA) was the only coverage offered mark
"No".

551

Yes - This government unit - Continue with
Question 2
Yes - Another government unit

1
4

➤

Exclude any retirees that have coverage through PHSA
(COBRA) or state continuation-of-benefits laws. See the
definition sheet MEPS-20(D) included with this package
for an explanation of these terms.

672

Enter name of other government unit
Continue with Question 2 if information is
available. Otherwise SKIP to Page 9, Section G.
551

No

2

Don’t know

3

2.

In a typical month, how many retirees were
enrolled in health insurance through your
government unit?

}

SKIP to Page 9, Section G

513

Number of retirees enrolled

UNDER 65 YEARS OF AGE

3a.

628

If this was a self-insured plan, report the premium
equivalent.
Were any of the enrolled retirees, reported in
Question 2, under 65 years of age?

b. In a typical month, how many retirees under

1

Yes - Continue with Question 3b

2

No

3

Don’t know

572

573

%

ENROLLED in SINGLE coverage?

d. For a typical plan in 2016, how much did the
GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with SINGLE coverage?

e. For this same plan, what was the TOTAL

Retirees under 65 enrolled in single
coverage

574

$

,

.00

Government unit
contribution for single premium

$

,

.00

Total single premium

$

,

.00

Government unit
contribution for family premium

$

,

.00

575

monthly premium for this typical retiree with
SINGLE coverage?

f. For a typical plan in 2016, how much did the

SKIP to Page 8, Question 4a

Number of retirees under 65
enrolled in health insurance

65 years of age were enrolled in health
insurance through your government unit?

c. What percentage of those retirees were

}

576

GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with FAMILY coverage?

29186079

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

Total family premium

Continue with Page 8, Question 4a
FORM MEPS-11

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

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Section F – RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
AGE 65 YEARS OR OVER
Exclude any retirees that have coverage through
PHSA (COBRA) or state continuation-of-benefits laws.

629

If this was a self-insured plan, report the premium
equivalent.

4a. Were any of the enrolled retirees, reported in

Yes - Continue with Question 4b

2

No
Don’t know

3

Question 2, 65 years of age or over?

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

1

}

578

Number of retirees 65 years or over
enrolled in health insurance

of age or over were enrolled in health insurance
through your government unit?

c. What percentage of these retirees were

579

ENROLLED in SINGLE coverage?

d. For a typical plan in 2016, how much did the

%

$

,

.00

Government unit
contribution for single premium

$

,

.00

Total single premium

$

,

.00

Government unit
contribution for family premium

$

,

.00

Total family premium

581

monthly premium for this typical retiree with
SINGLE coverage?

f. For a typical plan in 2016, how much did the

Retirees 65 years or over enrolled in
single coverage

580

GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with SINGLE coverage?

e. For this same plan, what was the TOTAL

SKIP to Question 5a

582

GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with FAMILY coverage?
For retirees, if premium varied by family size, report for
a family of two.

g. For this same plan, what was the TOTAL

583

monthly premium for this typical retiree with
FAMILY coverage?
NEW RETIREES

630

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

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

5a. Did your government unit offer health insurance
to any NEW RETIREES?

b. Were NEW RETIREES under 65 years of age
29186087

eligible for health insurance?

SKIP to Page 9, Section G

631

eligible for health insurance?

c. Were NEW RETIREES 65 years of age or over

}

632

Continue with Page 9, Section G
FORM MEPS-11

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For Questions 5a through 5c, NEW RETIREES refers
only to persons who retired from your government unit
in 2016.

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500

Remarks

*** PLEASE NOTE ***

29186095

If your government unit DID NOT offer health insurance, please complete
Section G and END the form.

Section G – PERSON COMPLETING THIS QUESTIONNAIRE
212

Name (Please print)

215

Area code

213

220

Number
–

–

Extension

214

MM

Title (Please print)

DD

YYYY

–

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-11

§>3]¢¤

If your government unit offered health insurance, please complete
Section G and an attached MEPS-11(S), Plan Information Questionnaire,
for each plan offered.