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pdfOMB No. 0935-0110: Approval Expires 11/30/2018
2017 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
29017019
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-10 (05-04-2017)
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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 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.
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.
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, Mail Stop 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 on the front page of this form.
FORM MEPS-10
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29017027
7. If you have any questions or need assistance in completing the
questionnaire, please call
or visit: econhelp.census.gov/meps
3
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 2017?
001
1
Yes – Continue with 2
2
No – SKIP to 3
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 organization make available or
contribute to for its ACTIVE employees at this
location during the 2017 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.
PRIOR YEAR OFFERING
In 2016, 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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3.
Continue with 4
FORM MEPS-10
4
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.
4.
What was the total number of employees your
organization had at ALL locations for a TYPICAL
pay period in 2017?
034
Employees at all locations
Complete Questions 5 through 11 for THE LOCATION
listed on the cover sheet.
200
b.
c.
6a.
How many employees were on your
organization’s payroll AT THIS LOCATION
for a TYPICAL pay period in 2017?
If your organization did not offer health insurance
in 2017, SKIP to 6a
How many of these employees were ELIGIBLE
for at least one health plan through your
organization?
201
How many of these employees were ENROLLED
in ANY health plan through your organization?
202
For the same TYPICAL pay period in 2017, how
many of the employees reported in Question 5a
worked part-time?
203
Eligible employees
Enrolled employees
Part-time employees
If your organization did not offer health insurance
in 2017, SKIP to 7
If none, enter "0".
b.
c.
7.
All employees at this
location
How many of these part-time employees were
ELIGIBLE for at least one health plan through
your organization?
204
How many of these part-time employees were
ENROLLED in ANY health plan through your
organization?
205
How many of the employees reported in
Question 5a worked fewer than 30 hours
per week?
742
Eligible part-time employees
Enrolled part-time employees
Employees worked fewer
than 30 hours
743
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8.
Is the information you provided in Questions 5,
6 and 7 above for the location listed on the
cover sheet OR did you provide information for
multiple locations?
No employees worked fewer than 30 hours
550
1
Information for specified location
2
Information for multiple locations
If your organization did not offer health insurance
in 2017, SKIP to 10a
9.
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 10a
FORM MEPS-10
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5a.
5
EMPLOYMENT CHARACTERISTICS - Continued
Provide information for a TYPICAL pay period in 2017.
Estimates are acceptable.
The following workforce characteristics are used to group
similar organizations together for analytical purposes.
10a. 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
%
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".
c. Approximately what percentage of the
017
employees at this location were 50 years old
or older?
If none, enter "0".
d. For the employees at this location 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
%
e. For the employees at this location in 2017,
approximately 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
FRINGE BENEFITS CHARACTERISTICS
29017050
11.
Did your organization offer the following fringe
benefits to its employees at this location
in 2017?
If Paid Time Off (PTO) is offered, mark (X) Yes for paid
vacation AND paid sick leave.
Yes
(1)
050
Paid vacation . . . . . . . . . . . . . . . . .
051
Paid sick leave . . . . . . . . . . . . . . . .
052
Life insurance. . . . . . . . . . . . . . . . .
053
Disability insurance . . . . . . . . . . . . .
054
Retirement/pension plans. . . . . . . . .
Don’t
No know
(2)
(3)
Continue with 12
FORM MEPS-10
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If none, enter "0".
6
FRINGE BENEFITS CHARACTERISTICS - Continued
12.
Did your organization offer any of these
tax-advantaged benefits to its employees at
this location in 2017?
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)
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 for its employees in 2017, continue with 13 .
If your organization DID NOT make available or contribute to the cost of any health insurance
coverage for its employees in 2017, SKIP to 22 .
HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS
13.
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).)
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
Organization not eligible
4
Don’t know
1
Yes
2
No
3
Don’t know
SMALL BUSINESS, 100 or FEWER EMPLOYEES
14.
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15.
744
Did your organization offer health insurance
through a Small Business Health Options
Program (SHOP) exchange or marketplace
in your state?
Will your organization claim a Small Business
Health Care Tax Credit on its 2017 federal
taxes?
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 $50,000
or less, AND 3) pays at least half of the health insurance
premiums for its employees.
16.
Did your organization use a third party, such
as an insurance broker or agent, to help
purchase the insurance plan(s)?
FORM MEPS-10
770
Continue with 17a
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Complete Questions 14 through 16 only if your
organization 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 17a.
7
GENERAL HEALTH COVERAGE CHARACTERISTICS
17a. Which of the listed optional coverage services,
if any, did your organization offer to its ACTIVE
employees at this location in 2017 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 18
Report single service insurance plans only.
Continue with 17b
Mark (X) all that apply.
720
coverage for all ACTIVE employees during a
TYPICAL MONTH at this location in 2017?
$
19.
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20.
21.
For 2017, 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 through your organization?
Were employees’ SPOUSES eligible for health
insurance coverage through your organization?
,
.00
Monthly optional coverage cost
Include both employer and employee contributions.
18.
,
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 paid 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 22
FORM MEPS-10
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b. What was the total amount paid for optional
8
RETIREE HEALTH COVERAGE CHARACTERISTICS
Please complete Questions 22 through 26 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.
22.
551
Did your organization provide health insurance
coverage to any person who retired in 2017 OR
BEFORE, or to any of their survivors?
If COBRA was the only coverage offered, mark "No."
23.
In a typical month, how many retirees were
enrolled in health insurance through your
organization at all locations?
1
Yes – Continue with 23
2
No
3
Don’t know
}
SKIP to Page 10 to
complete form
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 24b
2
No
24a. Were any of the enrolled retirees, reported in
Question 23, 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 2017, how much did the
%
,
.00
Employer contribution for
single premium
$
,
.00
Total single premium
$
,
.00
Employer contribution for
family premium
$
,
.00
Total family premium
576
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with FAMILY
coverage?
29017084
$
575
monthly premium for this typical retiree with
SINGLE coverage?
f. For a typical plan in 2017, 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
SKIP to 25a
572
years of age were enrolled in health insurance
through your organization at all locations?
c. What percentage of these retirees were
}
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
Continue with 25a
FORM MEPS-10
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If this was a self-insured plan, report the premium
equivalent.
9
RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
AGE 65 OR OLDER
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
25a. Were any of the enrolled retirees, reported in
1
Yes – Continue with 25b
2
No
3
Don’t know
Question 23, age 65 or older?
b. In a typical month, how many retirees age 65 or
}
578
Number of retirees age 65 or older
enrolled in health insurance
older were enrolled in health insurance through
your organization at all locations?
c. What percentage of these retirees were
579
%
ENROLLED in SINGLE coverage?
d. For a typical plan in 2017, how much did the
$
,
.00
Employer contribution for
single premium
$
,
.00
Total single premium
$
,
.00
Employer 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
EMPLOYER contribute toward the monthly plan
premium for one typical retiree with SINGLE
coverage?
e. For this same plan, what was the TOTAL
SKIP to 26a
582
EMPLOYER 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?
For Questions 26a through 26c, NEW RETIREES refers
only to persons who retired from your organization in 2017.
630
Exclude any retirees that have coverage through COBRA
or state continuation-of-benefits laws.
26a. Did your organization offer health insurance to
29017092
any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
1
Yes – Continue with 26b
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 age 65 or older eligible
632
for health insurance?
}
SKIP to Page 10
to complete form
Continue with Page 10
to complete form
FORM MEPS-10
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NEW RETIREES
10
500
Remarks
PERSON COMPLETING THIS QUESTIONNAIRE
Name (Please print)
Title (Please print)
212
213
Area code
Number
220
Extension
MM
DD
YYYY
214
–
–
–
Email
29017100
217
*** PLEASE NOTE ***
If your organization offered health insurance, please complete an attached MEPS-10(S),
Plan Information Questionnaire, for each plan offered (up to four plans).
If your organization DID NOT offer health insurance, you have completed the survey.
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-10
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215
| File Type | application/pdf |
| File Modified | 2017-05-04 |
| File Created | 2017-05-04 |