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pdfOMB 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.
| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2022-11-15 |
| File Created | 2022-03-09 |