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pdfOMB No. 0935-0110: Approval Expires 11/30/2018
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
Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health
insurance plans offered in 2016 AT THIS GOVERNMENT UNIT. Please use photocopies
of this MEPS-11(S) form if sufficient copies were not included in this reporting package.
GENERAL PLAN INFORMATION
Begin with the plan having the largest enrollment and proceed through to the plan with the smallest enrollment of
ACTIVE employees.
Please photocopy this MEPS-11(S) questionnaire if additional forms are needed.
1.
For 2016, what was the name of the health
insurance plan with the largest (or next
largest) enrollment of ACTIVE employees?
012
Name of plan
2.
Which type of health care provider
arrangement was available through this plan?
103
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.
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
29046018
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.
Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order
to be referred to a specialist?
For plans with multiple options, answer for the
"in-network" option.
104
Continue with Page 2, Question 4
FORM MEPS-11(S) (03-29-2016)
§>%]3¤
Examples: • Blue Cross Blue Shield, High Option
• Option A
• Aetna HMO
2
GENERAL PLAN INFORMATION
- Continued
|
4.
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 6
2
Self-insured - Continue with Question 5a
3
Don’t know - SKIP to Question 6
Self-insured - Your government unit 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
5a.
Complete Questions 5a-c if this plan was self-insured.
Did your government unit employ a third party
administrator (TPA) or purchase administrative
services only (ASO) from an insurer for this
self-insured plan?
713
1
Yes - Used a TPA or ASO
2
No - Self-administered the plan
coverage for this plan?
1
Yes
(see definition sheet MEPS-20(D) for more information)
2
No - SKIP to Question 6
b. Did your government unit purchase stop-loss
c. What was the specific stop-loss amount PER
107
732
$
EMPLOYEE?
,
,
.00
ACTUARIAL VALUE OR METAL LEVEL
What was this plan’s actuarial value OR metal
level?
Actuarial Value:
747
%
Actuarial Value is the percentage of medical
expenses paid by the plan rather than out-of-pocket
for a typical group of enrollees.
Metal Levels are labels for insurance plans that
describe the level of benefits and cost-sharing provisions.
OR
Metal Level:
746
776
29046026
of medical expenses paid by plan
1
Bronze
2
Silver
3
Gold
4
Platinum
6
N/A, Grandfathered Plan
Don’t know
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
7a. How many ACTIVE employees were
ENROLLED in this plan at this government
unit during a typical pay period in 2016?
125
Active employees enrolled
in plan
Include full-time, part-time, temporary and seasonal
employees.
Exclude retirees, former employees, leased or contract
workers.
FORM MEPS-11(S)
Continue with Page 3, Question 7b
§>%];¤
6.
3
ACTIVE ENROLLMENT – Continued
7b. How many of these ACTIVE employees were
129
Active employees enrolled in
single coverage
ENROLLED in SINGLE coverage during a
typical pay period in 2016?
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 government unit offered EMPLOYEEPLUS-ONE coverage, how many ACTIVE
employees were ENROLLED during a typical
pay period in 2016?
571
Active employees enrolled in
employee-plus-one
coverage
Include enrollment for both employee-plus-spouse and
employee-plus-child coverage.
d. How many of these ACTIVE employees were
ENROLLED in FAMILY (not single or employeeplus-one) coverage during a typical pay period
in 2016?
705
Active employees enrolled in
family coverage
PHSA (COBRA ENROLLMENT)
8.
How many FORMER employees were
ENROLLED in this plan, excluding retirees,
through PHSA (COBRA) or state continuationof-benefits laws during a typical pay period in
2016?
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 government unit/employee contributions and total premium for the same period in 2016.
SINGLE COVERAGE
552
9a. Was SINGLE coverage offered under this plan?
b. For this plan, how much did the GOVERNMENT
1
Yes - Continue with Question 9b
2
No - SKIP to Page 4, Question 10a
131
UNIT contribute toward the plan premium of
one typical employee with SINGLE coverage?
c. How much did this typical EMPLOYEE with
based on which one of the following time
periods?
29046034
.00
Employer contribution for
single premium
$
,
.00
Employee contribution for
single premium
$
,
.00
Total single premium
130
employee with SINGLE coverage?
e. The amounts reported in Questions 9b-d are
,
132
SINGLE coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
$
133
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Mark (X) only one.
Continue with Page 4, Question 10a
FORM MEPS-11(S)
§>%]C¤
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.
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
10a. Was EMPLOYEE-PLUS-ONE coverage offered
under this plan?
b. For this plan, how much did the GOVERNMENT
1
Yes - Continue with Question 10b
2
No - SKIP to Question 11a
636
UNIT contribute toward the plan premium of
one typical employee with EMPLOYEEPLUS-ONE coverage?
c. How much did this typical EMPLOYEE with
,
.00
Employee contribution for
employee-plus-one premium
$
,
.00
Total employee-plus-one
premium
638
are based on which one of the following time
periods?
Mark (X) only one.
FAMILY COVERAGE
$
635
employee with EMPLOYEE-PLUS-ONE
coverage?
e. The amounts reported in Questions 10b-d
Government unit contribution
for employeeplus-one
premium
637
EMPLOYEE-PLUS-ONE coverage contribute
toward his/her own premium?
d. What was the TOTAL premium for this typical
,
.00
$
137
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
1
Yes - Continue with Question 11b
2
No - SKIP to Page 5, Question 12a
If premium varied by family size, report for a family of four.
11a. Was FAMILY coverage offered under this plan?
135
UNIT contribute toward the plan premium of
one typical employee with FAMILY coverage?
c. How much did this typical EMPLOYEE with
553
29046042
are based on which one of the following time
periods?
FAMILY coverage vary depending on the
number of family members covered by the
plan?
Government unit contribution
for family premium
$
,
.00
Employee contribution for
family premium
$
,
.00
Total family premium
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
1
Yes
2
No
3
Don’t know
Mark (X) only one.
f. Did the TOTAL premium reported earlier for
.00
134
employee with FAMILY coverage?
e. The amounts reported in Questions 11b-d
,
136
FAMILY coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
$
752
Continue with Page 5, Question 12a
FORM MEPS-11(S)
§>%]K¤
b. For this plan, how much did the GOVERNMENT
5
GENERAL PREMIUM INFORMATION
12a. Did the TOTAL premium reported earlier for
749
SINGLE coverage vary by the age of the
employee enrolled in the plan?
b. Did older EMPLOYEES contribute more
750
toward their SINGLE coverage premium
than younger employees?
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
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.
Yes
(1)
734
Participation in a fitness/weight
loss program . . . . . . . . . . . . . . . . . . .
735
Participation in a smoking
cessation program . . . . . . . . . . . . . . .
761
Wellness/Health monitoring. . . . . . . . .
No
(2)
Don’t
know
(3)
INDIVIDUAL DEDUCTIBLES
13a. Did this plan have a deductible?
151
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
1
Yes - Continue with Question 13b
2
No - SKIP to Page 6, Question 16
146
paid?
Report "in-network" deductibles (if applicable).
$
,
.00
Individual annual deductible
If separate deductibles apply, enter physician care and
hospital care amounts in appropriate boxes.
If deductible is per overnight hospital stay, it is not an
annual deductible and should be reported under
Question 17b on Page 6.
DO NOT report COPAYMENTS or individual or family
maximums here.
FAMILY DEDUCTIBLES
29046059
14a. 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
1
Yes - Continue with Question 14b
2
No - SKIP to Question 14c
3
Family coverage not offered - SKIP to Page 6,
Question 15
150
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?
Report for a family of four.
FORM MEPS-11(S)
Number of family members
149
$
,
.00
Total annual family deductible
Continue with Page 6, Question 15
§>%]\¤
If prescription drugs have a separate deductible, it
should be reported under Question 19c, Page 7.
6
HEALTH SAVINGS| ACCOUNT (HSA)
|
Complete only if the deductibles for this plan were $1,300
or higher for single coverage and/or $2,600 or higher for
family coverage, otherwise skip to Question 16.
15.
714
Did your government unit contribute to a
Health Savings Account (HSA) for the plan
enrollees in 2016?
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA
4
Don’t know
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
16.
710
Did your government unit offer an HRA
associated with this plan in 2016?
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.
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.
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.
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)..
Do not include any physician charges incurred during the
hospital admission.
18a. Was physician care covered under this plan?
29046067
b. How much and/or what percentage of the
total bill did an enrollee pay out-of-pocket
for a General Practitioner office visit, with
a participating physician, after any annual
deductible was met?
Out of pocket expense - Costs paid directly by
the enrollee.
Some plans may have both a dollar copayment and a
percentage coinsurance.
Report for an "in-network"/participating general
practitioner, excluding preventive care visits.
c. How much and/or what percentage of the total
155
Yes - Continue with Question 17b
2
No - SKIP to Question 18a
152
$
154
.00
,
1
Per day
2
Per stay
Copayment paid by enrollee for
hospital admission
AND/OR
153
%
218
Coinsurance paid by enrollee
1
Yes - Continue with Question 19b
2
No - SKIP to Page 7, Question 19a
156
$
.00
Copayment paid by enrollee for
office visit
AND/OR
157
%
Coinsurance paid by enrollee
771
bill did an enrollee pay out-of-pocket for a
Specialist Physician office visit after any
annual deductible was met?
Report for an "in-network"/participating specialist.
1
$
.00
Copayment paid by enrollee for
Specialist Physician office visit
AND/OR
772
%
Coinsurance paid by enrollee
Continue with Page 7, Question 19a
FORM MEPS-11(S)
§>%]d¤
17a. Was hospital care covered under this plan?
7
PAYMENTS - Continued
19a. Were prescription drugs covered under this
673
health plan?
b. Did this plan have a SEPARATE ANNUAL
773
deductible that applies only to prescription
drugs?
c. What was the ANNUAL deductible for
1
Yes - Continue with Question 19b
2
No
3
Don’t know
1
Yes - Continue with Question 19c
2
No
3
Don’t know
}
}
SKIP to Page 8, Question 20a
SKIP to Question 19d
774
prescription drugs for single coverage in this
plan?
$
.00
,
Report "in-network" deductibles (if applicable).
d. 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.
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
% Coinsurance
763
Preferred brand name not covered
Non-preferred brand name
757
$
.00
Copayment
AND/OR
%
29046075
764
Specialty drugs are prescription medications that are
used to treat complex, chronic and often costly conditions.
See definition sheet MEPS-20(D) for more information.
Coinsurance
Non-preferred brand name not covered
Specialty
767
$
.00
Copayment
AND/OR
768
%
769
Coinsurance
Specialty not covered
Continue with Page 8, Question 20a
FORM MEPS-11(S)
§>%]l¤
758
8
PAYMENTS - Continued
Include all copayments, coinsurance and deductibles.
161
20a. 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
Yes
this plan?
(1)
22. 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.
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
29046083
*** PLEASE NOTE ***
If your government unit offered only one health insurance plan, you
have completed your response to this survey.
If your government unit offered MORE THAN ONE health insurance
plan, please complete a Plan Information Questionnaire for each
plan that was offered.
Feel free to include any health insurance brochure information you
may have in your return packet or fax to 1-800-447-4615.
FORM MEPS-11(S)
Don’t
No know
(2)
(3)
§>%]t¤
21. Which of the services listed were covered by
| File Type | application/pdf |
| File Modified | 2016-03-29 |
| File Created | 2016-03-29 |