Download:
pdf |
pdfOMB No. 0935-0110: Approval Expires 11/30/2020
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
2019 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2019 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.
1
For 2019, what was the name of the health
insurance plan with the largest (or next
largest) enrollment of ACTIVE employees?
012
Name of plan
Examples: • Blue Cross Blue Shield, High Option
• Option A
• Aetna HMO
Which type of health care provider arrangement
was available through this plan?
Exclusive providers - Enrollees must go to "in-network"
providers associated with the plan for all non-emergency
care in order for the costs to be covered.
29029014
3
103
1
Exclusive providers
Any providers - Enrollees may go to providers of their
choice with no cost incentives to use a particular group of
providers. This is also known as an indemnity plan.
2
Any providers
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 providers and any providers
1
Yes
2
No
3
Don’t know
1
Union (multi-employer health plan)
2
Trade or business association (AHP)
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
Was this plan offered through a union
(multi-employer health plan) or a trade or business
association (Association Health Plan (AHP))?
Multi-employer Health Plan – An employee health benefit plan
maintained pursuant to a collective bargaining agreement that
includes employees of two or more employers.
Association Health Plan (AHP) – A group health plan that
employer groups and associations offer to provide health
coverage for their employees or members.
FORM MEPS-10(S) (02-15-2019) Draft 7
113
Continue with 5
§>#{/¤
2
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
6
a. Did your organization employ a third party
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 7
administrator (TPA) or purchase
administrative services only (ASO) from an
insurer for this self-insured plan?
b. Did your organization purchase stop-loss
c. What was the stop-loss amount PER
107
732
$
ENROLLEE?
,
,
.00
ACTUARIAL VALUE OR METAL LEVEL
7
What was this plan’s actuarial value OR metal
level?
Actuarial Value:
747
%
Actuarial Value is the average percentage of total
enrollee medical expenses for plan covered benefits
paid by the plan, rather than by enrollee cost
sharing, for a typical group of enrollees.
of medical expenses paid by plan
OR
29029022
746
776
1
Bronze
2
Silver
3
Gold
4
Platinum
6
N/A, Grandfathered Plan
§>#{7¤
Metal Level:
Metal Levels are labels for insurance plans that
describe the level of benefits and cost-sharing
provisions.
Don’t know
Continue with 8a
FORM MEPS-10(S)
3
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
For Questions 8a through 8d, if the answer is NONE, please enter "0".
Include:
• Full-time and part-time employees
• Temporary and seasonal employees
8
Exclude:
• Retirees
• Former employees
• Leased or contract workers
a. How many active employees were enrolled
125
in this plan at this location during a typical
pay period?
b. How many of these active employees
Active employees enrolled in plan
,
Active employees enrolled in
single coverage
,
Active employees enrolled in
employee-plus-one coverage
,
Active employees enrolled in
family coverage
,
Former employees enrolled in
plan, excluding retirees
129
were enrolled in SINGLE coverage during
a typical pay period?
c. If this plan had EMPLOYEE-PLUS-ONE
coverage, how many active employees were
enrolled during a typical pay period?
,
571
Include enrollment for both employee-plus-spouse and
employee-plus-child coverage.
d. How many active employees were enrolled in
FAMILY coverage during a typical pay period?
705
COBRA ENROLLMENT
9
How many FORMER employees were enrolled
in this plan, excluding retirees, through COBRA
or state continuation-of-benefits laws during a
typical pay period?
126
PLAN PREMIUMS
Report for TYPICAL situations and enrollees. If premiums varied, report for a TYPICAL employee.
If this was a self-insured plan, report the premium equivalent.
10
The following questions, 11a through 13e,
refer to plan premium amounts. For which
time period will you be reporting?
29029030
Mark (X) only one.
790
1
Weekly
2
Every 2 weeks
3
Monthly
5
Quarterly
4
Yearly
§>#{?¤
Report employer/employee contributions and total premium for the same period during 2019.
Continue with 11a
FORM MEPS-10(S)
4
PLAN PREMIUMS - Continued
SINGLE COVERAGE
11 a. Was SINGLE coverage offered under this
552
plan?
b. For this plan, how much did the EMPLOYER
1
Yes - Continue with 11b
2
No - SKIP to 12a
131
contribute toward the plan premium of one
typical employee with single coverage?
c. How much did this typical EMPLOYEE with
,
.00
Employer contribution for
single premium
$
,
.00
Employee contribution for
single premium
$
,
.00
Total single premium
132
single coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this
$
130
typical employee with single coverage?
EMPLOYEE-PLUS-ONE COVERAGE
If employee-plus-one premiums were different for employee-plus-child and employee-plus-spouse coverage, report for
employee-plus-one child. If premiums varied for other reasons, report for a TYPICAL employee.
12
a. Was EMPLOYEE-PLUS-ONE coverage offered
570
under this plan?
b. For this plan, how much did the EMPLOYER
1
Yes - Continue with 12b
2
No - SKIP to 13a
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
637
employee-plus-one coverage contribute
toward his/her own premium?
d. What was the TOTAL premium for this typical
$
635
employee with employee-plus-one coverage?
FAMILY COVERAGE
13
a. Was FAMILY coverage offered under this
137
plan?
b. For this plan, how much did the EMPLOYER
1
Yes - Continue with 13b
2
No - SKIP to 14a
135
29029048
contribute toward the plan premium of one
typical employee with family coverage?
c. How much did this typical EMPLOYEE with
vary depending on the number of family
members covered by the plan?
FORM MEPS-10(S)
.00
Employer contribution for
family premium
$
,
.00
Employee contribution for
family premium
$
,
.00
Total family premium
134
employee with family coverage?
e. Did the TOTAL premium for family coverage
,
136
family coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
$
752
1
Yes
2
No
3
Don’t know
Continue with 14a
§>#qI¤
If premium varied by family size, report for a family of four.
5
GENERAL PREMIUM INFORMATION
14
a. 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.
b. Was the TOTAL PREMIUM for an employee
Yes
(1)
734
Participation in a fitness/weight
loss program . . . . . . . . . . . . . . . . . . .
735
Participation in a smoking
cessation program . . . . . . . . . . . . . . .
761
Wellness/Health monitoring . . . . . . . . .
784
Age. . . . . . . . . . . . . . . . . . . . . . . . . .
785
Wage or Salary levels. . . . . . . . . . . . .
749
with single coverage higher for older
workers?
1
Yes
2
No
3
Don’t know
No
(2)
Don’t
know
(3)
DEDUCTIBLES
16
Did this plan have a deductible?
What were the annual deductibles in this
plan for different levels of coverage?
Report "in-network" deductibles (if applicable).
If prescription drugs had a separate deductible, it
should be reported under Question 22c on Page 7.
149
meet their individual deductibles before the
family deductible was met?
29029055
2
No - SKIP to 19a
$
,
.00
Individual annual deductible
$
,
.00
Employee-plus-one
annual deductible
Employee-plus-one coverage not offered
$
792
,
.00
Family annual deductible
Family coverage not offered
224
of family members meet their individual
deductibles before the family deductible
was met?
b. How many family members were required to
Yes - Continue with 16
786
791
a. Did this plan require that a specific number
1
146
If deductible was per overnight hospital stay, it is not
an annual deductible and should be reported under
Question 20b on Page 7.
DO NOT report COPAYMENTS or individual or family
out-of-pocket maximums here.
17
151
1
Yes - Continue with 17b
2
No
3
Family coverage not offered
}
SKIP to 18a
150
Number of family members
Report for a family of four.
Continue with 18a
FORM MEPS-10(S)
§>#{X¤
15
6
HEALTH SAVINGS ACCOUNT (HSA)
Complete only if the deductibles for this plan were $1,350 or higher for single coverage and/or $2,700 or higher for family
coverage, otherwise skip to Question 19a.
18
a. Did your organization contribute to a Health
714
Savings Account (HSA) for the plan enrollees?
b. What was the MONTHLY contribution your
1
Yes, contributed to an HSA
2
No, did not contribute
to an HSA
4
Don’t know
777
organization made to the HSA for a typical
employee with single coverage for this plan?
}
SKIP to 19a
$
,
.00
Monthly HSA contribution for
single coverage
$
,
.00
Monthly HSA contribution for
family coverage
This amount should NOT include the amount your
organization contributed toward the plan premium.
c. What was the MONTHLY contribution your
778
organization made to the HSA for a typical
employee with family coverage for this plan?
This amount should NOT include the amount your
organization contributed toward the plan premium.
Report for a family of four.
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
19
a. Did your organization offer a Health
710
Reimbursement Arrangement (HRA)
associated with this plan?
An employer can offer an HRA by setting up an
account to reimburse employees for medical expenses
not covered by health insurance.
1
Yes, contributed to an HRA
2
No, did not contribute
to an HRA
3
Don’t know
}
SKIP to 20a
HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs). See definition sheet
MEPS-20(D) for more information.
b. Up to what dollar amount did your
779
organization contribute ANNUALLY to a
typical employee’s HRA for single coverage
for this plan?
$
,
.00
Annual HRA contribution for
single coverage
$
,
.00
Annual HRA contribution for
family coverage
c. Up to what dollar amount did your
29029063
organization contribute ANNUALLY to a
typical employee’s HRA for family coverage
for this plan?
780
This amount should NOT include the amount your
organization contributed toward the plan premium.
Report for a family of four.
Continue with 20a
FORM MEPS-10(S)
§>#{‘¤
This amount should NOT include the amount your
organization contributed toward the plan premium.
7
PAYMENTS
20
a. Was hospital care covered under this plan?
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?
155
1
Yes - Continue with 20b
2
No - SKIP to 21a
152
$
154
.00
,
1
Per day
2
Per stay
Copayment paid by enrollee for
hospital admission
Report for precertified hospital admissions (if applicable).
Report for an admission at an "in-network"/participating
hospital (if applicable).
AND/OR
153
Do not include any physician charges incurred during the
hospital admission.
21
a. Was physician care covered under this plan?
b. How much and/or what percentage of the
%
218
Coinsurance paid by enrollee
1
Yes - Continue with 21b
2
No - SKIP to 22a
156
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?
$
.00
Copayment paid by enrollee for
office visit
AND/OR
157
Report for an "in-network"/participating general
practitioner, excluding preventive care visits.
771
total 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,
excluding preventive care visits.
22
a. Were prescription drugs covered under this
$
for prescription drugs for single coverage in
this plan?
Report "in-network" prescription deductibles for
participating pharmacies (if applicable).
FORM MEPS-10(S)
29029071
Copayment paid by enrollee for
Specialist Physician office visit
AND/OR
%
673
773
deductible that applies only to prescription
drugs?
c. What was the SEPARATE ANNUAL deductible
.00
772
health plan?
b. Did this plan have a SEPARATE ANNUAL
Coinsurance paid by enrollee
Coinsurance paid by enrollee
1
Yes - Continue with 22b
2
No
3
Don’t know
1
Yes - Continue with 22c
2
No
3
Don’t know
}
}
SKIP to 23
SKIP to 22d
774
$
,
.00
Separate individual prescription
drug deductible
Continue with 22d
§>#{h¤
c. How much and/or what percentage of the
%
8
PAYMENTS - Continued
22
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
754
%
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
%
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
Specialty not covered
787
out-of-pocket expense for specialty drugs?
$
793
Include all copayments, coinsurance and deductibles.
29029089
23
What was the overall MAXIMUM ANNUAL
out-of-pocket expense?
,
.00
Maximum annual out-of-pocket
expense for specialty drugs
No specialty drug maximum
161
$
,
.00
Maximum out-of-pocket expense
for an individual
OR
163
No individual maximum
This is often referred to as a catastrophic limit.
788
$
,
.00
Maximum out-of-pocket expense
for employee-plus-one
OR
789
No employee-plus-one maximum
162
$
,
.00
Maximum out-of-pocket expense
for a family
OR
222
FORM MEPS-10(S)
No family maximum
Continue with 24
§>#{z¤
e. What was the maximum annual
Coinsurance
9
PLAN CHARACTERISTICS
24
Which of the services listed were covered by
this plan?
Telemedicine is the delivery of health care through
telecommunications to a patient from a provider who
is at a remote location.
25
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 . . . . . . . .
781
Telemedicine. . . . . . . . . . . . . . . . . . .
739
1
Yes
2
No
3
Don’t know
Don’t
No know
(2)
(3)
*** PLEASE NOTE ***
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.
29029097
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)
§>#{¿¤
If your organization offered only one health insurance plan,
you have completed your response to this survey.
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |