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pdfOMB No. 0935-0110: Approval Expires 11/30/2018
2017 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
29187010
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 (05-04-2017)
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AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
2
INSTRUCTIONS
1. Please report for the government unit identified on the cover sheet,
unless otherwise specified.
2. Please report data for the year 2017.
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 estimate this survey will take 45 minutes, on average, to complete, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If
you offered more than two plans, we estimate an extra 11 minutes per additional plan. 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 send questionnaire to the
address printed on the front page of this form.
FORM MEPS-11
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29187028
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
3
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 2017?
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 2017 plan year?
1
Yes - Continue with 2
2
No - SKIP to 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 2016, 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
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.
How many employees were on your
government unit’s payroll for a TYPICAL pay
period in 2017?
740
All employees
If your government did not offer health insurance
in 2017, SKIP to 5a
29187036
b.
c.
How many of these employees were ELIGIBLE
for at least one health plan through your
government unit?
201
How many of these employees were
ENROLLED in ANY health plan through your
government unit?
202
Eligible employees
Enrolled employees
Continue with 5a
FORM MEPS-11
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4a.
4
EMPLOYMENT CHARACTERISTICS – Continued
5a.
For the same TYPICAL pay period in 2017,
how many employees reported in Question 4a
worked part-time?
759
Part-time employees
If your government unit did not offer health
insurance in 2017, SKIP to 6
If none, enter "0".
b.
c.
6.
How many of these part-time employees were
ELIGIBLE for at least one health plan through
your government unit?
204
How many of these part-time employees were
ENROLLED in ANY health plan through your
government unit?
205
How many of the employees reported in
Question 4a worked fewer than 30 hours per
week?
Eligible part-time employees
Enrolled part-time employees
742
743
Employees worked fewer
than 30 hours
No employees worked fewer than 30 hours
If your government unit did not offer health
insurance in 2017, SKIP to 8a
7.
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
Provide information for a TYPICAL pay period in 2017.
Estimates are acceptable.
8a.
b.
The following workforce characteristics are used to
group similar government units together for analytical
purposes.
018
Approximately what percentage of the
employees at this government unit were
union members?
729
Approximately what percentage of the
employees at this government unit were
women?
%
Union members
No union members
016
%
Women employees
%
Employees 50 years old or older
%
Earned less than $12.00 per hour
%
Earned between $12.00 and $29.50
per hour
%
Earned more than $29.50 per hour
If none, enter "0".
Approximately what percentage of the
employees at this government unit were 50
years old or older?
017
If none, enter "0".
29187044
d.
For the employees at this government unit in
2017, approximately what percentage earned –
If none, enter "0".
022
Less than $12.00 per hour? . . . . . . . . . . . . . . . . . .
Approximately $25,000 a year or less
023
Between $12.00 and $29.50 per hour? . . . . . . . .
Approximately $25,000 to $61,000 a year
024
More than $29.50 per hour? . . . . . . . . . . . . . . . . .
Approximately $61,000 a year or more
1 0 0
%
Continue with 8e
FORM MEPS-11
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c.
5
EMPLOYMENT CHARACTERISTICS – Continued
8e.
For the employees at this government unit in
2017, how many earned more than $46.00 per
hour?
726
Number of employees that earned
more than $46.00 per hour
Approximately $96,000 a year or more
If none, enter "0".
FRINGE BENEFITS CHARACTERISTICS
|
9.
Did your government unit offer the following
fringe benefits to its employees in 2017?
If Paid Time Off (PTO) is offered, mark (X) Yes for paid
vacation AND paid sick leave.
10.
Did your government unit offer any of these
tax-advantaged benefits to its employees
in 2017?
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)
If your government unit DID make available or contribute to the cost of any health insurance
coverage for its employees in 2017, continue with 11 .
29187051
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If your government unit DID NOT make available or contribute to the cost of any health
insurance coverage for its employees in 2017, SKIP to 18 .
Continue with 11
FORM MEPS-11
6
|
HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS
11.
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 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
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
SMALL GOVERNMENT, 100 OR FEWER EMPLOYEES
Complete questions 12 through 13 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 14a.
12.
13.
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)?
770
GENERAL HEALTH COVERAGE CHARACTERISTICS
14a. 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 15
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 2017?
$
29187069
Include both government unit and employee contributions.
15.
For 2017, did your government unit impose a
waiting period before new employees could
be covered by health insurance?
}
Continue with 14b
,
,
.00
Monthly optional coverage cost
197
1
Yes
2
No
3
Don’t know
Continue with 16
FORM MEPS-11
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if any, did your government unit offer to its
ACTIVE employees in 2017 at a premium
SEPARATE from the comprehensive health
plan premium?
7
GENERAL HEALTH COVERAGE CHARACTERISTICS – Continued
16.
17.
Were employees’ SPOUSES eligible for health
insurance coverage through your government
unit?
745
All spouses eligible, greater EMPLOYEE
CONTRIBUTION paid if spouses eligible
through own employer.
5
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)
RETIREE HEALTH COVERAGE CHARACTERISTICS
18.
Does your government unit or some other
government unit provide health insurance
coverage to any person who retired in 2017
OR BEFORE, or to any of their survivors?
551
4
Yes - Another government unit
Enter name of other government unit
Continue with 19 if information is available.
Otherwise SKIP to Page 9 to complete form.
551
In a typical month, how many retirees were
enrolled in health insurance through your
government unit?
Yes - This government unit - Continue with 19
672
If PHSA (COBRA) was the only coverage offered mark
"No".
19.
1
➤
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.
2
No
3
Don’t know
}
SKIP to bottom of Page 9
to complete form
513
Number of retirees enrolled
Exclude any retirees that have coverage through PHSA
(COBRA) or state continuation-of-benefits laws.
29187077
20a.
628
If this was a self-insured plan, report the premium
equivalent.
Were any of the enrolled retirees, reported in
Question 19, under 65 years of age?
b. In a typical month, how many retirees under
1
Yes - Continue with 20b
2
No
3
Don’t know
572
573
%
ENROLLED in SINGLE coverage?
d. For a typical plan in 2017, how much did the
GOVERNMENT UNIT contribute toward the
monthly plan premium for one typical retiree
with SINGLE coverage?
FORM MEPS-11
SKIP to 21a
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
}
Retirees under 65 enrolled in single
coverage
574
$
,
.00
Government unit
contribution for single premium
Continue with 20e
§>3gn¤
UNDER 65 YEARS OF AGE
8
RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
20e. For this same plan, what was the TOTAL
575
monthly premium for this typical retiree with
SINGLE coverage?
f. For a typical plan in 2017, how much did the
$
,
.00
Total single premium
$
,
.00
Government unit
contribution for family premium
$
,
.00
576
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
577
monthly premium for this typical retiree
with FAMILY coverage?
Total family premium
AGE 65 OR OLDER
629
If this was a self-insured plan, report the premium
equivalent.
21a. Were any of the enrolled retirees, reported in
Yes - Continue with 21b
2
No
Don’t know
3
Question 19, age 65 or older?
b. In a typical month, how many retirees age 65
1
578
579
%
ENROLLED in SINGLE coverage?
d. For a typical plan in 2017, 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 2017, how much did the
Retirees age 65 or older 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 22a
Number of retirees age 65 or older
enrolled in health insurance
or older were enrolled in health insurance
through your government unit?
c. What percentage of these retirees were
}
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.
29187085
g. For this same plan, what was the TOTAL
monthly premium for this typical retiree with
FAMILY coverage?
583
Continue with 22a
FORM MEPS-11
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Exclude any retirees that have coverage through
PHSA (COBRA) or state continuation-of-benefits laws.
9
RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
NEW RETIREES
For Questions 22a through 22c, NEW RETIREES refers
only to persons who retired from your government unit
in 2017.
630
Exclude any retirees that have coverage through PHSA
(COBRA) or state continuation-of-benefits laws.
22a. Did your government unit offer health
insurance to any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
}
SKIP to next Section
to complete form
632
for health insurance?
500
Yes - Continue with 22b
631
eligible for health insurance?
c. Were NEW RETIREES age 65 or older eligible
1
Remarks
PERSON COMPLETING THIS QUESTIONNAIRE
Name (Please print)
Title (Please print)
212
213
Area code
Number
220
Extension
MM
DD
YYYY
214
–
–
–
Email
29187093
217
*** PLEASE NOTE ***
If your government unit offered health insurance, please complete an attached
MEPS-11(S), Plan Information Questionnaire, for each plan offered.
If your government unit DID NOT offer health insurance, you have completed the
survey.
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-11
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215
| File Type | application/pdf |
| File Modified | 2017-10-05 |
| File Created | 2017-05-04 |