Form #3 Plan Questionnaire

OMB No. 0935-0110: Approval Expires 02/28/2023
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

2022 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2022 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 2022, what was the name of the health
insurance plan with the largest (or next
largest) enrollment of ACTIVE employees?

012

Name of plan

Examples: Ⴠ Blue Cross Blue Shield, High Option
Ⴠ Option A
Ⴠ 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.

29022019

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)

(03-09-2022) D2

113

Continue with 5

§>#54¤

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 - Continue with 6c

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 AND/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

AND/OR

29022027

746
1

Bronze

2

Silver

3

Gold

4

Platinum

§>#5<¤

Metal Level:
Metal Levels are labels for insurance plans that
describe the level of benefits and cost-sharing
provisions.

OR
Don’t know actuarial
value or metal level

776

8

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.

739
1

Yes

2

No

3

Don’t know
Continue with 9a

FORM

MEPS-10(S)

3

ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
For Questions 9a through 9d, if the answer is NONE, please enter "0".
Include:
ჀCorporate officers and managers
ჀEmployees on the payroll for this location, including:
- those who work off-site
- those who are leased or contracted TO other organizations
ჀFull-time and part-time employees
ჀOwners
ჀTemporary and seasonal employees

9

a. How many active employees were enrolled

Exclude:
ჀFormer employees
ჀWorkers leased or contracted
FROM other organizations
ჀRetirees

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
10 How many FORMER employees were enrolled

126

in this plan through COBRA or state
continuation-of-benefits laws during a typical
pay period? Exclude retirees.

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.

11

The following questions, 12a through 14e,
refer to plan premium amounts. For which
time period will you be reporting?

29022035

Mark (X) only one.

790
1

Weekly

2

Every 2 weeks

3

Monthly

5

Quarterly

4

Yearly

§>#5D¤

Report employer/employee contributions and total premium for the same period during 2022.

Continue with 12a
FORM

MEPS-10(S)

4

PLAN PREMIUMS - Continued
SINGLE COVERAGE

12 a. Was SINGLE coverage offered under this

552

plan?

b. For this plan, how much did the EMPLOYER

1

Yes - Continue with 12b

2

No - SKIP to 13a

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.

13

a. Was EMPLOYEE-PLUS-ONE coverage offered

570

under this plan?

b. For this plan, how much did the EMPLOYER

1

Yes - Continue with 13b

2

No - SKIP to 14a

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

14

a. Was FAMILY coverage offered under this

137

plan?

b. For this plan, how much did the EMPLOYER

1

Yes - Continue with 14b

2

No - SKIP to 15a

135

contribute toward the plan premium of one
typical employee with family coverage?
29022043

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 15a

§>#5L¤

If premium varied by family size, report for a family of four.

5

GENERAL PREMIUM INFORMATION
15

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)

IN-NETWORK DEDUCTIBLES

17

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).

151
1

Yes - Continue with 17

2

No - SKIP to 21

146

If deductible was per overnight hospital stay, it is not
an annual deductible and should be reported under
Question 23b on Page 7.

791

If prescription drugs had a separate deductible, it
should be reported under Question 25c on Page 8.

149

a. Did this plan require that a specific number

29022050

meet their individual deductibles before the
family deductible was met?

.00

Individual annual deductible

$



.00

Employee-plus-one
annual deductible

Employee-plus-one coverage not offered.

$



.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



786

792

18

$

1

Yes - Continue with 18b

2

No

3

Family coverage not offered.

}

SKIP to 19

150

Number of family members

Report for a family of four.

Continue with 19
FORM

MEPS-10(S)

§>#5S¤

16

6

HEALTH SAVINGS ACCOUNT (HSA)
Complete only if the deductibles for this plan were $1,400 or higher for single coverage and/or $2,800 or higher for
employee-plus-one or family coverage, otherwise skip to Question 21.

19

20

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

a. What was the MONTHLY contribution your

714
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 21

$



.00

Monthly HSA contribution for
single coverage

$



.00

Monthly HSA contribution for
employee-plus-one coverage

$



.00

Monthly HSA contribution for
family coverage

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

b. What was the MONTHLY contribution your

799

organization made to the HSA for a typical
employee with employee-plus-one coverage
for this plan?
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)
21

Did your organization contribute to a Health
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.
DO NOT report ICHRA or QSEHRA here.

710
1

Yes, contributed to an HRA

2

No, did not contribute
to an HRA

3

Don’t know

}

SKIP to 23a

29022068

§>#5e¤

HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs). See definition sheet
MEPS-20(D) for more information.

Continue with 22a
FORM

MEPS-10(S)

7

HEALTH REIMBURSEMENT ARRANGEMENT (HRA) - Continued
22 a. 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
employee-plus-one coverage

$



.00

Annual HRA contribution for
family coverage

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

b. Up to what dollar amount did your

800

organization contribute ANNUALLY to a
typical employee’s HRA for employeeplus-one coverage for this plan?
This amount should NOT include the amount your
organization contributed toward the plan premium.

c. Up to what dollar amount did your

780

organization contribute ANNUALLY to a
typical employee’s HRA for 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.

IN-NETWORK PAYMENTS
23

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 23b

2

No - SKIP to 24a

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

%

Coinsurance paid by enrollee

29022076

§>#5m¤

Do not include any physician charges incurred during
the hospital admission.

Continue with 24a
FORM

MEPS-10(S)

8

IN-NETWORK PAYMENTS - Continued
24

a. Was physician care covered under this plan?

b. How much and/or what percentage of the

218

1

Yes - Continue with 24b

2

No - SKIP to 25a

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
General Practitioner 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

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.

25

a. Were prescription drugs covered under this

%
673

773

Coinsurance paid by enrollee

1

Yes - Continue with 25b

2

No

}

SKIP to 26

3

Don’t know

1

Yes - Continue with 25c

2

No

3

for prescription drugs for single coverage in
this plan?

Copayment paid by enrollee for
Specialist Physician office visit

AND/OR

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

Don’t know

}

SKIP to 25d

774

$



.00

Separate individual prescription
drug deductible

29022084

§>#5u¤

Report "in-network" prescription deductibles for
participating pharmacies (if applicable).

Continue with 25d
FORM

MEPS-10(S)

9

IN-NETWORK PAYMENTS - Continued
25

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

26

Specialty not covered

161

$

What was the overall MAXIMUM ANNUAL
out-of-pocket expense?



.00

OR
163

No individual maximum

This is often referred to as a catastrophic limit.
788

Report “in-network” maximum out-of-pocket
expense (if applicable).
29022092

Maximum out-of-pocket expense
for an individual

$



.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

No family maximum

Continue with 27
FORM

MEPS-10(S)

§>#5}¤

Include all copayments, coinsurance and deductibles.

Coinsurance

10

PLAN CHARACTERISTICS
27

Did this plan cover any of the services listed?

Yes
(1)

Telemedicine is the delivery of health care through
telecommunications to a patient from a provider who
is at a remote location.

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 . . . . . . . . . . . . . . . . . . .

Don’t
No know
(2)

(3)

OUT-OF-NETWORK DEDUCTIBLES AND PAYMENTS
Does this plan cover any of the costs of
non-emergency out-of-network care?

If this plan had an out-of-network deductible, continue
with Question 29, otherwise skip to Question 30.

29

What was the annual deductible an enrollee
paid out-of-pocket for care provided by an
out-of-network provider for different levels of
coverage?
If deductible was per overnight hospital stay, it is not
an annual deductible and should be reported under
Question 30.

801
1

Yes

2

No

3

Don’t know

}

Skip to the bottom of
page 11 for instructions.

.00

Out-of-network individual
annual deductible

.00

Out-of-network
employee-plus-one
annual deductible

802

$



803

$
804



Employee-plus-one coverage not offered.

805

$
806

.00



Out-of-network family
annual deductible

Family coverage not offered.

If this plan offered hospital care, continue with
Question 30, otherwise skip to Question 31.

29022100

30

For an out-of-network provider, 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?

807

$
808

Report for precertified hospital admissions
(if applicable).

.00



1

Per day

2

Per stay

Copayment paid by enrollee for
out-of-network hospital admission

AND/OR
Do not include any physician charges incurred during
the hospital admission.

809

%

Coinsurance paid by enrollee for
out-of-network hospital admission

Continue with 31
FORM

MEPS-10(S)

§>#6!¤

28

11

OUT-OF-NETWORK DEDUCTIBLES AND PAYMENTS - Continued
Include all copayments, coinsurance and deductibles.

31

What was the maximum annual out-of-pocket
expense for care provided by an out-of-network
provider?
This is often referred to as a catastrophic limit.

810

$



.00

Out-of-network maximum
out-of-pocket expense for
an individual

OR
811

No individual maximum

812

$



.00

Out-of-network maximum
out-of-pocket expense for
employee-plus-one

OR
813

No employee-plus-one maximum

814

$



.00

Out-of-network maximum
out-of-pocket expense for
a family

OR
815

No family maximum

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

29022118

To supplement your response, you may include Summary
of Benefits and Coverage or other materials describing plan
benefits and premiums in your return packet or fax to
1-800-447-4613.

FORM

MEPS-10(S)

§>#63¤

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.