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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
The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health
insurance plans offered in 2019 AT THIS GOVERNMENT UNIT. Please use photocopies
of this MEPS-11(S) form if sufficient copies were not included in this reporting package.
GENERAL PLAN INFORMATION
Begin with the plan having the largest enrollment and proceed through to the plan with the smallest enrollment of
ACTIVE employees.
Please photocopy this MEPS-11(S) questionnaire if additional forms are needed.
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
2
Which type of health care provider
arrangement was available through this plan?
103
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.
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.
1
Exclusive providers
2
Any providers
3
Mixture of preferred providers and any providers
1
Yes
2
No
3
Don’t know
3
Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order
to be referred to a specialist?
For plans with multiple options, answer for the
"in-network" option.
104
§>%{-¤
29049012
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.
Continue with 4
FORM MEPS-11(S) (02-15-2019) Draft 5
2
GENERAL PLAN INFORMATION
- Continued
|
4
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 6
2
Self-insured - Continue with 5a
3
Don’t know - SKIP to 6
Self-insured - Your government unit 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
5
a. Did your government unit employ a third
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 6
party administrator (TPA) or purchase
administrative services only (ASO) from an
insurer for this self-insured plan?
b. Did your government unit purchase stop-loss
c. What was the stop-loss amount
107
732
PER ENROLLEE?
$
,
,
.00
ACTUARIAL VALUE OR METAL LEVEL
6
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
29049020
746
776
1
Bronze
2
Silver
3
Gold
4
Platinum
6
N/A, Grandfathered Plan
§>%{5¤
Metal Level:
Metal Levels are labels for insurance plans that
describe the level of benefits and cost-sharing provisions.
Don’t know
Continue with 7
FORM MEPS-11(S)
3
ACTIVE ENROLLMENT – Continued
Estimates are acceptable for all enrollment figures.
For Questions 7a through 7d, if the answer is NONE, please enter "0".
Include:
• Full-time and part-time employees
• Temporary and seasonal employees
7
Exclude:
• Retirees
• Former employees
• Leased or contract workers
a. How many active employees were enrolled
125
in this plan at this government unit 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
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
PHSA (COBRA ENROLLMENT)
8
How many FORMER employees were enrolled in
this plan, excluding retirees, through PHSA
(COBRA) or state continuation-of-benefits laws
during a typical pay period?
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 government unit/employee contributions and total premium for the same period in 2019.
9
The following questions, 10a through 12e,
refer to plan premium amounts. For which
time period will you be reporting?
790
1
Weekly
5
Quarterly
2
Every 2 weeks
4
Yearly
3
Monthly
Mark (X) only one.
10 a. Was SINGLE coverage offered under this
552
29049038
plan?
b. For this plan, how much did the GOVERNMENT
typical employee with single coverage?
2
No - SKIP to 11a
$
,
.00
Government unit 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
Yes - Continue with 10b
131
UNIT contribute toward the plan premium of
one typical employee with single coverage?
c. How much did this typical EMPLOYEE with
1
130
Continue with 11a
FORM MEPS-11(S)
§>%{G¤
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.
11 a. Was EMPLOYEE-PLUS-ONE coverage offered
570
under this plan?
b. For this plan, how much did the GOVERNMENT
1
Yes - Continue with 11b
2
No - SKIP to 12a
636
UNIT contribute toward the plan premium of
one typical employee with employee-plus-one
coverage?
c. How much did this typical EMPLOYEE with
,
.00
Government unit 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
If premium varied by family size, report for a family of four.
137
12 a. Was FAMILY coverage offered under this
1
Yes - Continue with 12b
2
No - SKIP to 13a
plan?
b. For this plan, how much did the GOVERNMENT
135
UNIT contribute toward the plan premium of
one typical employee with family coverage?
c. How much did this typical EMPLOYEE with
Government unit contribution
for family premium
$
,
.00
Employee contribution for
family premium
$
,
.00
Total family premium
752
1
Yes
2
No
3
Don’t know
29049046
§>%qQ¤
family coverage vary depending on the
number of family members covered by the
plan?
.00
134
employee with family coverage?
e. Did the TOTAL premium reported earlier for
,
136
family coverage contribute toward his/her
own premium?
d. What was the TOTAL premium for this typical
$
Continue with 13a
FORM MEPS-11(S)
5
GENERAL PREMIUM INFORMATION
13 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
15
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 21c on Page 7.
149
meet their individual deductibles before the
family deductible was met?
29049053
2
No - SKIP to 18a
$
,
.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 15
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 19b on Page 7.
DO NOT report COPAYMENTS or individual or family
out-of-pocket maximums here.
16
151
1
Yes - Continue with 16b
2
No
3
Family coverage not offered
}
SKIP to 17a
150
Number of family members
Report for a family of four.
Continue with 17a
FORM MEPS-11(S)
§>%{V¤
14 Did this plan have a deductible?
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 18a.
17
a. Did your government unit contribute to a
714
Health Savings Account (HSA) for the plan
enrollees?
1
Yes, contributed to an HSA
2
No, did not contribute
to an HSA
Don’t know
4
b. What was the MONTHLY contribution your
government unit made to the HSA for a
typical employee with single coverage for
this plan?
777
}
SKIP to 18a
$
,
.00
Monthly HSA contribution
for single coverage
$
,
.00
Monthly HSA contribution
for family coverage
This amount should NOT include the amount your
government unit contributed toward the plan
premium.
c. What was the MONTHLY contribution your
government unit made to the HSA for a
typical employee with family coverage for
this plan?
778
This amount should NOT include the amount your
government unit contributed toward the plan
premium.
Report for a family of four.
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
18
a. Did your government unit offer a Health
710
Reimbursement Arrangement (HRA)
associated with this plan?
1
Yes, contributed to an HRA
An employer can offer an HRA by setting up an
account to reimburse employees for medical
expenses not covered by health insurance.
2
No, did not contribute
to an HRA
3
Don’t know
}
SKIP to 19a
b. Up to what dollar amount did your
government unit contribute ANNUALLY
to a typical employee’s HRA for single
coverage for this plan?
779
$
,
.00
Annual HRA contribution
for single coverage
$
,
.00
Annual HRA contribution
for family coverage
This amount should NOT include the amount your
government unit contributed toward the plan
premium.
29049061
c. Up to what dollar amount did your
government unit contribute ANNUALLY
to a typical employee’s HRA for FAMILY
coverage for this plan?
780
This amount should NOT include the amount your
government unit contributed toward the plan
premium.
Report for a family of four.
Continue with 19a
FORM MEPS-11(S)
§>%{^¤
HRAs are NOT Flexible Spending Accounts (FSAs)
or Health Savings Accounts (HSAs). See definition
sheet MEPS-20(D) for more information.
7
PAYMENTS
19 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
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?
2
No - SKIP to 20a
$
154
Report for an admission at an "in-network"/participating
hospital (if applicable).
20 a. Was physician care covered under this plan?
Yes - Continue with 19b
152
Report for precertified hospital admissions (if applicable).
Do not include any physician charges incurred during the
hospital admission.
1
.00
,
1
Per day
2
Per stay
AND/OR
153
%
218
Coinsurance paid by enrollee
1
Yes - Continue with 20b
2
No - SKIP to 21a
156
$
.00
Copayment paid by enrollee for
office visit
AND/OR
157
%
Report for an "in-network"/participating general
practitioner, excluding preventive care visits.
c. How much and/or what percentage of the
Copayment paid by enrollee for
hospital admission
Coinsurance paid by enrollee
771
total bill did an enrollee pay out-of-pocket
for a Specialist Physician office visit after
any annual deductible was met?
$
.00
Copayment paid by enrollee for
Specialist Physician office visit
AND/OR
772
21 a. Were prescription drugs covered under this
%
673
health plan?
b. Did this plan have a SEPARATE ANNUAL
773
29049079
deductible that applies only to prescription
drugs?
c. What was the SEPARATE ANNUAL deductible
for prescription drugs for single coverage in
this plan?
Coinsurance paid by enrollee
1
Yes - Continue with 21b
2
No
3
Don’t know
1
Yes - Continue with 21c
2
No
3
Don’t know
}
}
SKIP to 22a
SKIP to 21d
774
$
,
.00
Separate individual prescription
drug deductible
Report "in-network" prescription deductibles
for participating pharmacies (if applicable).
Continue with 21d
FORM MEPS-11(S)
§>%{p¤
Report for an "in-network"/participating specialist,
excluding preventive care visits.
8
PAYMENTS - Continued
21 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.
29049087
22
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-11(S)
No family maximum
Continue with 23
§>%{x¤
e. What was the maximum annual
Coinsurance
9
PLAN CHARACTERISTICS
23 Which of the services listed were covered by
Yes
this plan?
(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 . . . . . . . . . . . . . .
Telemedicine is the delivery of health care through
telecommunications to a patient from a provider who
is at a remote location.
182
Substance abuse treatment . . . . . . .
781
Telemedicine . . . . . . . . . . . . . . . . . .
24 Was this a grandfathered health plan as defined
739
by the Affordable Care Act?
See the definition sheet MEPS-20(D) included with this
package for an explanation.
1
Yes
2
No
3
Don’t know
Don’t
No know
(2)
(3)
29049075
If your government unit offered only one health insurance plan, you
have completed your response to this survey.
If your government unit offered MORE THAN ONE health insurance
plan, please complete a Plan Information Questionnaire for each
plan that was offered.
Feel free to include any health insurance brochure information you
may have in your return packet or fax to 1-800-447-4615.
FORM MEPS-11(S)
§>%{¢¤
*** PLEASE NOTE ***
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |