Form #3 Form #3 Plan Questionnaire

OMB 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

2018 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2018 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 2018, 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?

29028016

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

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1.

Continue with 5
FORM MEPS-10(S) (11-21-2017) Draft 1

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

29028024

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 2018?

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

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7.

3

ACTIVE ENROLLMENT – Continued
8b.

How many of these ACTIVE employees were
ENROLLED in SINGLE coverage during a
typical pay period in 2018?

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 2018?

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 2018?

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
2018 ?

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 2018.
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

29028032

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)

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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?
29028040

.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)

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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 17a

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

29028057

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 16a

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 16a
FORM MEPS-10(S)

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FAMILY DEDUCTIBLES

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 17.

714

16a. Did your organization contribute to a Health
Savings Account (HSA) for the plan enrollees
in 2018?

b. What is the monthly contribution your
organization makes to the HSA for a typical
employee with SINGLE coverage for this plan?

1

Yes, contributed to an HSA

2

No, did not contribute to an HSA

4

Don’t know

777

$

,

.00

$

,

.00

This amount should NOT include the amount your
organization contributes toward the plan premium.

c. What is the monthly contribution your
organization makes to the HSA for a typical
employee with FAMILY coverage for this plan?

778

This amount should NOT include the amount your
organization contributes toward the plan premium.

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
17a. Did your organization offer a Health

710

Reimbursement Arrangement (HRA)
associated with this plan in 2018?

1

Yes

An employer can offer an HRA by setting up an
account to reimburse employees for medical
expenses not covered by health insurance.

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.

b. Up to what dollar amount does your
organization contribute EACH YEAR to
a typical employee’s HRA for SINGLE
coverage for this plan?

779

$

,

.00

$

,

.00

This amount should NOT include the amount your
organization contributes toward the plan premium.

organization contribute EACH YEAR to
a typical employee’s HRA for FAMILY
coverage for this plan?

780

§>#qb¤

c. Up to what dollar amount does your

29028065

This amount should NOT include the amount your
organization contributes toward the plan premium.

Continue with 18a
FORM MEPS-10(S)

7

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?

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

AND/OR
%

218

Yes - Continue with 19b

2

No - SKIP to 20a

156

$

.00

AND/OR
%

for prescription drugs for SINGLE coverage in
this plan?

29028073

Coinsurance paid by enrollee

771

$

.00

Copayment paid by enrollee for
Specialist Physician office visit

AND/OR
772

673

773

deductible that applies only to prescription
drugs?

c. What was the SEPARATE ANNUAL deductible

Copayment paid by enrollee for
office visit

157

health plan?

b. Did this plan have a SEPARATE ANNUAL

Coinsurance paid by enrollee

1

%

20a. Were prescription drugs covered under this

Copayment paid by enrollee for
hospital admission

153

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

Coinsurance paid by enrollee

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

$

,

.00

Separate prescription drug
deductible

Report "in-network" prescription deductibles for
participating pharmacies (if applicable).
Continue with 20d
FORM MEPS-10(S)

§>#qj¤

18a. Was hospital care covered under this plan?

8

PAYMENTS - Continued
20d. 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

%
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

Include all copayments, coinsurance and deductibles.
161

$

out-of-pocket expense for an individual?
Out-of-pocket expense - Those costs paid directly
by the enrollee.
163

29028081

.00

OR
No individual maximum

This is often referred to as a catastrophic limit.

b. What was the MAXIMUM ANNUAL

,

§>#qr¤

21a. What was the MAXIMUM ANNUAL

162

$

out-of-pocket expense for a family of four?

,

.00

OR
222

No family maximum

Continue with 22
FORM MEPS-10(S)

9

PLAN CHARACTERISTICS
22.

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, including video chat and
remote monitoring.

23.

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.

29028099

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)

§>#qƒ¤

If your organization offered only one health insurance plan,
you have completed your response to this survey.