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pdfOMB No. 0935-0110: Approval Expires 11/30/2020
Medical Expenditure Panel Survey
Insurance Component
2019 HEALTH INSURANCE
COST STUDY
Government Questionnaire
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
29189016
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 (02-15-2019) Draft 6
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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 2019.
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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29189024
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 offer any health
insurance plans to its ACTIVE employees in
2019?
001
1
Yes - Continue with
2
No - SKIP to
2
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 government unit offer to its
ACTIVE employees during the 2019 plan year?
003
Health insurance plan choices
Do not count single service plans (optional plans) such
as dental or vision.
• Single, employee-plus-one, and family coverage
providing the same level of benefits from the same
insurance company count as ONE plan.
• High and standard options count as TWO plans.
• An HMO and a PPO from the same insurance
company count as TWO plans.
PRIOR YEAR OFFERING
In 2018, did your government unit offer any
health insurance plans to its ACTIVE
employees?
760
1
Yes – Offered
2
No – Not offered
3
Don’t know
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3
Continue with 4a
FORM MEPS-11
4
EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility, and enrollment figures.
For Questions 4a through 8e, if the answer is NONE, please enter "0".
Include:
Exclude:
• Full-time and part-time employees
• Former employees
• Temporary and seasonal employees
• Leased or contract workers
• Retirees
4
a. How many employees were on your
740
government unit’s payroll for a typical
pay period in 2019?
,
All employees
782
No employees – SKIP to Page 9 to complete form
If your government unit did not offer
health insurance in 2019, SKIP to 5a .
b. How many of these employees were
201
ELIGIBLE for at least one health plan
through your government unit?
c. How many of these employees were
a. For the same TYPICAL pay period, how
Eligible employees
,
Enrolled employees
,
Part-time employees
202
ENROLLED in any health plan through
your government unit?
5
,
759
many employees reported in Question 4a
worked part-time?
If your government unit did not offer
health insurance in 2019, SKIP to 6 .
204
were ELIGIBLE for at least one health
plan through your government unit?
c. How many of these part-time employees
How many of the employees reported in
Question 4a worked fewer than 30 hours per
week?
Eligible part-time employees
,
Enrolled part-time employees
,
Employees worked fewer
than 30 hours
205
were ENROLLED in any health plan
through your government unit?
6
,
742
743
No employees worked fewer than 30 hours.
If your government unit did not offer
health insurance in 2019, SKIP to 8a .
29189040
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.
Continue with 8a
FORM MEPS-11
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b. How many of these part-time employees
5
EMPLOYMENT CHARACTERISTICS – Continued
Provide information for a TYPICAL pay period in 2019.
Estimates are acceptable.
8
a. Approximately what percentage of the
018
%
employees at this government unit were
union members?
729
b. Approximately what percentage of the
No union members
016
employees at this government unit were
women?
c. Approximately what percentage of the
Union members
%
Women employees
%
Employees 50 years old or older
%
Earned less than $12.50 per hour
%
Earned between $12.50 and $30.50
per hour
%
Earned more than $30.50 per hour
017
employees at this government unit were
50 years old or older?
d. For the employees at this government
unit, approximately what percentage
earned –
022
Less than $12.50 per hour?
Approximately $26,000 a year or less . . . . . . . . . . . . . . . . . .
023
Between $12.50 and $30.50 per hour?
Approximately $26,000 to $63,000 a year . . . . . . . . . . . . . . .
024
More than $30.50 per hour?
Approximately $63,000 a year or more . . . . . . . . . . . . . . . . . .
1 0 0
e. For the employees at this government
%
726
unit, how many earned more than $47.50
per hour?
,
Number of employees that earned
more than $47.50 per hour
Approximately $99,000 a year or more
FRINGE BENEFITS CHARACTERISTICS
|
Did your government unit offer the following
fringe benefits to its employees?
29189057
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 10
FORM MEPS-11
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9
6
FRINGE BENEFITS CHARACTERISTICS – Continued
10
Did your government unit offer any of these
tax-advantaged benefits to its employees?
See the definition sheet MEPS-20(D) included with this
package for an explanation of these benefits.
Yes
(1)
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.
Don’t
No know
(2)
(3)
If your government unit offered health insurance, continue with 11 .
If your government unit DID NOT offer health insurance, SKIP to 17 .
HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS
11
Did your government unit offer health insurance
to active employees through a private exchange
(also known as a corporate exchange)?
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.
12
Did your government unit use a third party, such
as an insurance broker or agent, to help
purchase the insurance plan(s)?
1
Yes
2
No
3
Don’t know
If your government unit has more than 100 employees at all
locations, SKIP to 13a . Otherwise, continue with 12 .
770
1
Yes
2
No
3
Don’t know
GENERAL HEALTH COVERAGE CHARACTERISTICS
a. Which of the listed optional coverage services,
if any, did your government unit offer to its
active employees, at a premium SEPARATE
from the comprehensive health plan premium?
Report single service insurance plans only.
29189065
Do not include single services covered under a
comprehensive health plan.
Long-term care insurance helps to cover the cost of
institutional and home care required by the chronically ill
or disabled.
Mark (X) all that apply.
b. What was the total amount paid for optional
coverage for all active employees during a
TYPICAL MONTH?
Include both government unit and employee contributions.
192
Dental
193
Vision
194
Prescription drugs
195
Long-term care
562
}
Continue with 13b
No optional coverage – SKIP to 14
720
$
,
,
.00
Monthly total optional coverage cost
Continue with 14
FORM MEPS-11
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13
7
GENERAL HEALTH COVERAGE CHARACTERISTICS – Continued
14
15
16
Did your government unit impose a waiting
period before new employees could be covered
by health insurance?
Were employees’ SPOUSES eligible for health
insurance coverage through your government
unit?
197
745
1
Yes
2
No
3
Don’t know
5
All spouses eligible, HIGHER employee
contribution paid if spouse eligible through
own employer.
6
All spouses eligible, SAME employee
contribution.
7
All spouses eligible, don’t know employee
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
For Questions 17 through 19g, if the answer is NONE, please enter "0".
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.
17
If COBRA was the only coverage offered mark "No".
551
1
Yes - This government unit - Continue with 18
4
Yes - Another government unit
➤
Did your government unit or some other
government unit provide health insurance
coverage to any person who retired in 2019
OR BEFORE, or to any of their survivors?
672
Continue with 18 if information is available.
Otherwise, SKIP to Page 9 to complete form.
29189073
551
18
In a typical month, how many retirees were
enrolled in health insurance through your
government unit?
2
No
3
Don’t know
}
SKIP to Page 9 to
complete form.
513
,
Number of retirees enrolled
Continue with 19a
FORM MEPS-11
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Name of other government unit
8
RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
Exclude any retirees that have coverage through
COBRA or state continuation-of-benefits laws.
UNDER 65 YEARS OF AGE
628
If this was a self-insured plan, report the premium
equivalent.
1
Yes
2
No
3
Don’t
know
19 a. Were any of the enrolled retirees
reported in Question 18, under 65
years of age or age 65 or older?
b. In a typical month, what was the
TOTAL number of retirees, by age
category, enrolled in health insurance
through your government unit?
c. What percentage of these retirees,
572
573
by age category, were ENROLLED in
SINGLE coverage?
629
}
SKIP to
second
column
Total
under
65
,
%
AGE 65 OR OLDER
Percent of
under 65
enrolled
in single
1
Yes
2
No
3
Don’t
know
578
}
SKIP to
20a
Total
65 or
older
,
579
%
Percent of
65 or older
enrolled
in single
d. For a typical plan, how much did the
GOVERNMENT UNIT contribute, by age
category, toward the monthly plan
premium for one typical retiree with
SINGLE coverage?
e. For this same plan, what was the
TOTAL monthly premium, by age
category, for this typical retiree with
SINGLE coverage?
580
574
$
,
.00
$
,
.00
$
,
.00
$
,
.00
$
,
.00
581
575
$
,
.00
f. For a typical plan, how much did the
GOVERNMENT UNIT contribute, by
age category, toward the monthly
plan premium for one typical retiree
with FAMILY coverage?
582
576
$
,
.00
For retirees, if premium varied by family size,
report for a family of two.
g. For this same plan, what was the
577
583
$
,
.00
29189081
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TOTAL monthly premium, by age
category, for this typical retiree
with FAMILY coverage?
Continue with 20a
FORM MEPS-11
9
RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
NEW RETIREES
For Questions 20a through 20c, NEW RETIREES refers only to persons who retired from your government unit in 2019.
Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws.
630
1
Yes – Continue with 20b
2
No
20 a. Did your government unit offer health
insurance to any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
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?
500
}
SKIP to the bottom of this
page to complete form.
Remarks
PERSON COMPLETING THIS QUESTIONNAIRE
Name (Please print)
Title (Please print)
212
213
Area code
Number
220
215
Extension
MM
DD
YYYY
214
–
–
Email
29189099
217
*** PLEASE NOTE ***
If your government unit offered health insurance, please complete the
attached MEPS-11(S), Plan Information Questionnaire, for all plans 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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–
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |