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

OMB No. 0935-0110: Approval Expires 02/28/2023

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.

For 2022, what was the name of the health insurance plan with the largest (or next largest) enrollment of ACTIVE employees?

Examples:
- Blue Cross Blue Shield, High Option
- Option A
- Aetna HMO
Name of Plan ________________________________________________

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.

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.

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.

1 ▢ Exclusive providers

2 ▢ Any providers

3 ▢ Mixture of preferred providers and any providers

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.

1 ▢ Yes

2 ▢ No

3 ▢ Don't know

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.

1 ▢ Union (multi-employer health plan)

2 ▢ Trade or business assocation (AHP)

3 ▢ Neither

Was this plan purchased from an insurance underwriter or was it self-insured?

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.

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.

1 ▢ Purchased - SKIP to 7

2 ▢ Self-insured - Continue with 6a

3 ▢ Don't know - SKIP to 7

SELF-INSURED PLAN INFORMATION

a. Did your organization employ a third party administrator (TPA) or purchase administrative services only (ASO) from an insurer for this self-insured plan?

1 ▢ Yes - Used a TPA or ASO

2 ▢ No - Self-administered the plan

b. Did your organization purchase stop-loss coverage for this plan?

See definition sheet MEPS-20(D) for more information

1 ▢ Yes - Continue with 6c

2 ▢ No - SKIP to 7

c. What was the specific stop-loss amount PER ENROLLEE?

$ _________.00

ACTUARIAL VALUE OR METAL LEVEL

What was this plan's actuarial value AND/OR metal level?

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.

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

Actuarial Value:

____% of medical expenses paid by plan

AND/OR
Metal Level:

1 ▢ Bronze

2 ▢ Silver

3 ▢ Gold

4 ▢ Platinum
OR
▢ Don't know actuarial value or metal level

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.

1 ▢ Yes

2 ▢ No

3 ▢ Don't know

ACTIVE ENROLLMENT

Estimates are acceptable for all enrollment figures.

For Questions 9a through 9d, if the answer is NONE, please enter "0".

Include:

Corporate officers and managers

Employees on the payroll for this location, including:

those who work off-site

those who are leased or contracted TO other organizations

Full-time and part-time employees

Owners

Temporary and seasonal employees

Exclude:

Former employees

Workers leased or contracted FROM other organizations

Retirees

a. How many active employees were enrolled in this plan at this location during a typical pay period?

__________ Active employees enrolled in plan

b. How many of these active employees were enrolled in SINGLE coverage during a typical pay period?

__________ Active employees enrolled in single coverage

c. If this plan had EMPLOYEE-PLUS-ONE coverage, how many active employees were enrolled during a typical pay period?

Include enrollment for both employee-plus-spouse and employee-plus-child coverage.

__________ Active employees enrolled in employee-plus-one coverage

d. How many active employees were enrolled in FAMILY coverage during a typical pay period?

__________ Active employees enrolled in family coverage

COBRA ENROLLMENT

How many FORMER employees were enrolled in this plan through COBRA or state continuation-of-benefits laws during a typical pay period? Exclude retirees.

__________ Former employees enrolled in plan, excluding 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.

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

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

Mark (X) only one.

1 ▢ Weekly

2 ▢ Every 2 weeks

3 ▢ Monthly

5 ▢ Quarterly

4 ▢ Yearly

SINGLE COVERAGE

a. Was SINGLE coverage offered under this plan?

1 ▢ Yes - Continue with 12b

2 ▢ No - SKIP to 13a

b. For this plan, how much did the EMPLOYER contribute toward the plan premium of one typical employee with single coverage?

$ _________.00 Employer contribution for single premium

c. How much did this typical EMPLOYEE with single coverage contribute toward his/her own premium?

$ _________.00 Employee contribution for single premium

d. What was the TOTAL premium for this typical employee with single coverage?

$ _________.00 Total single premium

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.

a. Was EMPLOYEE-PLUS-ONE coverage offered under this plan?

1 ▢ Yes - Continue with 13b

2 ▢ No - SKIP to 14a

b. For this plan, how much did the EMPLOYER contribute toward the plan premium of one typical employee with employee-plus-one coverage?

$ _________.00 Employer contribution for employee-plus-one premium

c. How much did this typical EMPLOYEE with employee-plus-one coverage contribute toward his/her own premium?

$ _________.00 Employee contribution for employee-plus-one premium

d. What was the TOTAL premium for this typical employee with employee-plus-one coverage?

$ _________.00 Total employee-plus-one premium

FAMILY COVERAGE

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

a. Was FAMILY coverage offered under this plan?

1 ▢ Yes - Continue with 14b

2 ▢ No - SKIP to 15a

b. For this plan, how much did the EMPLOYER contribute toward the plan premium of one typical employee with family coverage?

$ _________.00 Employer contribution for family premium

c. How much did this typical EMPLOYEE with family coverage contribute toward his/her own premium?

$ _________.00 Employee contribution for family premium

d. What was the TOTAL premium for this typical employee with family coverage?

$ _________.00 Total family premium

e. Did the TOTAL premium for family coverage vary depending on the number of family members covered by the plan?

1 ▢ Yes

2 ▢ No

3 ▢ Don't know

GENERAL PREMIUM INFORMATION

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.

Participation in a fitness/weight loss program	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Participation in a smoking cessation program	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Wellness/Health monitoring	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Age	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Wage or Salary levels	1 ▢ Yes	2 ▢ No	3 ▢ Don't know

b. Was the TOTAL PREMIUM for an employee with single coverage higher for older workers?

1 ▢ Yes

2 ▢ No

3 ▢ Don't know

IN-NETWORK DEDUCTIBLES

Did this plan have a deductible?

1 ▢ Yes - Continue with 17

2 ▢ No - SKIP to 21

What were the annual deductibles in this plan for different levels of coverage?

Report "in-network" deductibles (if applicable).

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

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

$ _________.00 Individual annual deductible

$ _________.00 Employee-plus-one annual deductible

▢ Employee-plus-one coverage not offered.

$ _________.00 Family annual deductible

▢ Family coverage not offered.

a. Did this plan require that a specific number of family members meet their individual deductibles before the family deductible was met?

1 ▢ Yes - Continue with 18b

2 ▢ No - SKIP to 19

3 ▢ Family coverage not offered. - SKIP to 19

b. How many family members were required to meet their individual deductibles before the family deductible was met?

Report for a family of four.

____ Number of family members

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 employer-plus-one or family coverage, otherwise skip to Question 21.

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

1 ▢ Yes, contributed to an HSA

2 ▢ No, did not contribute to an HSA - SKIP to 21

4 ▢ Don't know - SKIP to 21

a. What was the MONTHLY contribution your organization made to the HSA for a typical employee with single coverage for this plan?

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

$ _________.00 Monthly HSA contribution for single coverage

b. What was the MONTHLY contribution your 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.

$ _________.00 Monthly HSA contribution for employee-plus-one coverage

c. What was the MONTHLY contribution your 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.

$ _________.00 Monthly HSA contribution for family coverage

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

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.

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

1 ▢ Yes, contributed to an HRA

2 ▢ No, did not contribute to an HRA - SKIP to 23a

3 ▢ Don't know - SKIP to 23a

a. Up to what dollar amount did your organization contribute ANNUALLY to a typical employee's HRA for single coverage for this plan?

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

$ _________.00 Annual HRA contribution for single coverage

b. Up to what dollar amount did your organization contribute ANNUALLY to a typical employee's HRA for employee-plus-one coverage for this plan?

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

$ _________.00 Annual HRA contribution for employee-plus-one coverage

c. Up to what dollar amount did your 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.

$ _________.00 Annual HRA contribution for family coverage

IN-NETWORK PAYMENTS

a. Was hospital care covered under this plan?

1 ▢ Yes - Continue with 23b

2 ▢ No - SKIP to 24a

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?

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.

$ _________.00 Copayment paid by enrollee for hospital admission

1 ▢ Per day

2 ▢ Per stay
AND/OR
____% Coinsurance paid by enrollee

a. Was physician care covered under this plan?

1 ▢ Yes - Continue with 24b

2 ▢ No - SKIP to 25a

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?

Report for an "in-network"/participating general practitioner, excluding preventive care visits.

$ _________.00 Copayment paid by enrollee for General Practitioner office visit
AND/OR
____% Coinsurance paid by enrollee

c. How much and/or what percentage of the 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.

$ _________.00 Copayment paid by enrollee for Specialist Physician office visit
AND/OR
____% Coinsurance paid by enrollee

a. Were prescription drugs covered under this health plan?

1 ▢ Yes - Continue with 25b

2 ▢ No - SKIP to 26

3 ▢ Don't know - SKIP to 26

b. Did this plan have a SEPARATE ANNUAL deductible that applies only to prescription drugs?

1 ▢ Yes - Continue with 25c

2 ▢ No - SKIP to 25d

3 ▢ Don't know - SKIP to 25d

c. What was the SEPARATE ANNUAL deductible for prescription drugs for single coverage in this plan?

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

$ _________.00 Separate individual prescription drug deductible

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

$ ______.00 Copayment
AND/OR
_____% Coinsurance

▢ Generic not covered

Preferred brand name

$ ______.00 Copayment
AND/OR
_____% Coinsurance

▢ Preferred brand name not covered

Non-preferred brand name

$ ______.00 Copayment
AND/OR
_____% Coinsurance

▢ Non-preferred brand name not covered

Specialty
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.
$ ______.00 Copayment
AND/OR
_____% Coinsurance

▢ Specialty not covered

Include all copayments, coinsurance and deductibles.

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

This is often referred to as a catastrophic limit.

Report "in-network" maximum out-of-pocket expense (if applicable).

$ _________.00 Maximum out-of-pocket expense for an individual
OR
▢ No individual maximum

$ _________.00 Maximum out-of-pocket expense for employee-plus-one
OR
▢ No employee-plus-one maximum

$ _________.00 Maximum out-of-pocket expense for a family
OR
▢ No family maximum

PLAN CHARACTERISTICS

Did this plan cover any of the services listed?

Chiropractic care	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Routine vision care for children	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Routine vision care for adults	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Routine dental care for children	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Routine dental care for adults	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Mental health care	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Substance abuse treatment	1 ▢ Yes	2 ▢ No	3 ▢ Don't know
Telemedicine is the delivery of health care through telecommunications to a patient from a provider who is at a remote location.
Telemedicine	1 ▢ Yes	2 ▢ No	3 ▢ Don't know

OUT-OF-NETWORK DEDUCTIBLES AND PAYMENTS

Does this plan cover any costs of the non-emergency out-of-network care?

1 ▢ Yes

2 ▢ No - SKIP to the bottom of this page for instructions.

3 ▢ Don't know - SKIP to the bottom of this page for instructions.

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

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.

$ _________.00 Out-of-network individual annual deductible

$ _________.00 Out of network employee-plus-one annual deductible

▢ Employee-plus-one coverage not offered.

$ _________.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.

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?

Report for precertified hospital admissions (if applicable).

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

$ _________.00 Copayment paid by enrollee for out-of-network hospital admission

1 ▢ Per day

2 ▢ Per stay

AND/OR
____% Coinsurance paid by enrollee for out-of-network hospital admission