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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
2017 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2017 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 2017, 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?
29027018
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
§>#g3¤
1.
Continue with 5
FORM MEPS-10(S) (03-29-2017) Draft 6
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 7
2
Self-insured - Continue with 6a
3
Don’t know - SKIP to 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 through 6c if this plan was
self-insured.
6a.
b.
Did your organization employ a third party
administrator (TPA) or purchase administrative
services only (ASO) from an insurer for this
self-insured plan?
Did your organization purchase stop-loss
coverage for this plan?
713
What was the specific stop-loss amount PER
ENROLLEE?
Yes - Used a TPA or ASO
2
No - Self-administered the plan
1
Yes
2
No - SKIP to 7
107
(see definition sheet MEPS-20(D) for more information)
c.
1
732
$
,
,
.00
ACTUARIAL VALUE OR METAL LEVEL
What was this plan’s actuarial value OR metal
level?
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.
Actuarial Value:
747
%
OR
Metal Level:
746
776
29027026
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.
8a.
How many ACTIVE employees were ENROLLED
in this plan at this location during a typical pay
period in 2017?
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-10(S)
Continue with 8b
§>#g;¤
7.
3
ACTIVE ENROLLMENT – Continued
8b.
How many of these ACTIVE employees were
ENROLLED in SINGLE coverage during a
typical pay period in 2017?
129
Active employees enrolled in
single coverage
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.
c.
If this plan had EMPLOYEE-PLUS-ONE
coverage, how many ACTIVE employees
were ENROLLED during a typical pay period
in 2017?
571
Active employees enrolled in
employee-plus-one coverage
Include enrollment for both employee-plus-spouse and
employee-plus-child coverage.
d.
How many ACTIVE employees were ENROLLED
in FAMILY (not single or employee-plus-one)
coverage during a typical pay period in 2017?
705
Active employees enrolled in
family coverage
COBRA ENROLLMENT
9.
How many FORMER employees were
ENROLLED in this plan, excluding retirees,
through COBRA or state continuation-ofbenefits laws during a typical pay period in
2017?
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 2017.
552
1
Yes - Continue with 10b
2
No - SKIP to 11a
10a. Was SINGLE coverage offered under this plan?
b. For this plan, how much did the EMPLOYER
131
contribute toward the plan premium of one
typical employee with SINGLE coverage?
c. How much did this typical EMPLOYEE with
29027034
d. What was the TOTAL premium for this
are based on which one of the following time
periods?
Mark (X) only one.
.00
$
,
.00
Employee contribution for
single premium
$
,
.00
Total single premium
130
typical employee with SINGLE coverage?
e. The amounts reported in Questions 10b-d
,
132
SINGLE coverage contribute toward his/her
own premium?
Employer contribution for
single premium
$
133
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Continue with 11a
FORM MEPS-10(S)
§>#gC¤
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
11a. Was EMPLOYEE-PLUS-ONE coverage offered
under this plan?
b. For this plan, how much did the EMPLOYER
1
Yes - Continue with 11b
2
No - SKIP to 12a
636
contribute toward the plan premium of one
typical employee with EMPLOYEE-PLUS-ONE
coverage?
c. How much did this typical EMPLOYEE with
.00
Employer contribution for
employee-plus-one premium
$
,
.00
Employee contribution for
employee-plus-one premium
$
,
.00
Total employee-plus-one
premium
635
employee with EMPLOYEE-PLUS-ONE
coverage?
e. The amounts reported in Questions 11b-d
,
637
EMPLOYEE-PLUS-ONE coverage contribute
toward his/her own premium?
d. What was the TOTAL premium for this typical
$
638
are based on which one of the following time
periods?
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
1
Yes - Continue with 12b
2
No - SKIP to 13a
Mark (X) only one.
FAMILY COVERAGE
137
If premium varied by family size, report for a family of four.
12a. Was FAMILY coverage offered under this plan?
135
contribute toward the plan premium of one
typical employee with FAMILY coverage?
c. How much did this typical EMPLOYEE with
553
are based on which one of the following time
periods?
29027042
.00
Employer contribution for
family premium
$
,
.00
Employee contribution for
family premium
$
,
.00
Total family premium
134
employee with FAMILY coverage?
e. The amounts reported in Questions 12b-d
,
136
FAMILY coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
$
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 for FAMILY
coverage vary depending on the number
of family members covered by the plan?
752
Continue with 13a
FORM MEPS-10(S)
§>#gK¤
b. For this plan, how much did the EMPLOYER
5
GENERAL PREMIUM INFORMATION
13a. 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
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
750
toward their SINGLE coverage premium
than younger employees?
c. Did the amount individual EMPLOYEES
Yes
(1)
contributed toward their SINGLE coverage
premium vary by any of these characteristics?
734
Do not include incentive programs that do not impact
contributions.
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
14a. 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 14b
2
No - SKIP to 17
146
paid?
$
,
.00
Individual annual deductible
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 18b on Page 6.
DO NOT report COPAYMENTS or individual or family
out-of-pocket maximums here.
If prescription drugs have a separate deductible, it
should be reported under Question 20c on Page 7.
15a. Did this plan require that a specific number
224
29027059
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 15b
2
No - SKIP to 15c
3
Family coverage not offered - SKIP to 16
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?
Number of family members
149
$
,
.00
Total annual family deductible
Report for a family of four.
Continue with 16
FORM MEPS-10(S)
§>#g\¤
FAMILY DEDUCTIBLES
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 17.
16.
714
Did your organization contribute to a Health
Savings Account (HSA) for the plan enrollees
in 2017?
1
Yes, contributed to an HSA
2
No, did not contribute to an HSA
4
Don’t know
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
17.
Did your organization offer an HRA associated
with this plan in 2017?
710
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.
19a. Was physician care covered under this plan?
29027067
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 18b
2
No - SKIP to 19a
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 19b
2
No - SKIP to 20a
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 20a
FORM MEPS-10(S)
§>#gd¤
18a. Was hospital care covered under this plan?
7
PAYMENTS - Continued
20a. 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 20b
2
No
3
Don’t know
1
Yes - Continue with 20c
2
No
3
Don’t know
}
}
SKIP to 21a
SKIP to 20d
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 after any annual
deductible was met?
Generic
753
$
.00
Copayment
AND/OR
Out-of-pocket expense - Costs paid directly by
the enrollee.
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
757
$
.00
Copayment
AND/OR
758
29027075
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 21a
FORM MEPS-10(S)
§>#gl¤
%
8
PAYMENTS - Continued
Include all copayments, coinsurance and deductibles.
161
21a. 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
23.
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
*** PLEASE NOTE ***
29027083
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.
Feel free to include any health insurance brochure information
you may have in your return packet or fax to 1-800-447-4613.
FORM MEPS-10(S)
Don’t
No know
(2)
(3)
§>#gt¤
22.
| File Type | application/pdf |
| File Modified | 2017-03-29 |
| File Created | 2017-03-29 |