1999 Medical Expenditure Panel Survey

Insurance Component

HEALTH INSURANCE 
COST STUDY

Establishment Questionnaire

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

RETURN TO

PLEASE DO NOT REMOVE COVER

INSTRUCTIONS

Paperwork Reduction Act and Burden Statements

We expect that it will take 45 minutes, on average, per establishment, to complete the basic questionnaire. Establishments with more than one health plan will take an additional 10 minutes per plan, on average, up to the maximum of four plans to be reported. In addition, we estimate that it will take 15 minutes to review the instructions and locate the requested information. You may send any comments regarding this burden estimate or any other aspect of the collection of information, including suggestions for reducing burden, to the following address: Director, Center for Cost and Financing Studies, Paperwork Reduction Project 0935-0110, Agency for Healthcare Research and Quality, Executive Office Center, Suite 500, 2101 East Jefferson Street, Rockville, MD 20852-4908.

Section A – NUMBER OF PLANS

Please respond for the location identified on the cover sheet unless otherwise specified.
Respond for active employees only.

For this survey, a health insurance plan is hospital and/or physician coverage made available to employees.

Yes – Continue with Question 1b
No – SKIP to Section B

Plans offered by the same insurance company which offer:

• Single and family plans providing the same level of benefits count as one plan.
• High and standard options count as two plans.
• An HMO and a conventional plan count as two plans.

SKIP to Page 4, Section C

Section B – HEALTH INSURANCE NOT OFFERED

1a. Did your organization offer any health insurance as a benefit to its employees at this location between January 1, 1994 and December 31, 1998?  

Yes – Continue with Question 1b 

No – SKIP to Question 2

 199___  Last year offered

Yes 

No

Yes – Continue with Question 3b 

No – SKIP to Page 4, Section C

Yes 

No

$ __________________ Voucher value

Mark (X) only one. 

____ Weekly 

____ Every 2 weeks 

____ Monthly 

____ Quarterly 

____ Yearly

Section C – EMPLOYMENT CHARACTERISTICS

Include officers, owners, part-time, temporary and seasonal employees. 

Exclude leased or contract workers.

1. What was the total number of employees your organization had at ALL locations for a typical pay period in 1999? 

_{______________} Employees at all locations 

2a. How many employees were on your organization’s payroll AT THIS LOCATION for a typical pay period in 1999? 

___________All employees at this location  

If your organization did not offer health insurance in 1999, SKIP to Question 3a.

_______ Eligible employees 

_______ Enrolled employees 

______ Part-time employees 

If your organization did not offer health insurance in 1999, SKIP to Question 4a.

______ Eligible part-time employees

______ Enrolled part-time employees 

______ Temporary or seasonal employees

If your organization did not offer health insurance in 1999, SKIP to Question 5.

______ Eligible temporary or seasonal employees

______ Enrolled temporary or seasonal employees 

Information for specified location 550 

Information for multiple locations

Section C – EMPLOYMENT CHARACTERISTICS – Continued

Estimates are acceptable.

The following workforce characteristics are used to group similar organizations together for analytical purposes.

6a. What percentage of the employees at this location were women? 

_{________}%  Women employees

_______ Employees 50 years old or older

______% Union members 

Less than $6.50 per hour? ...................
Approximately $13,000 a year or less

_____% Earned less than $6.50 per hour

Between $6.50 and $15.00 per hour? ...........
Approximately $13,000 to $30,000 a year

_____% Earned between $6.50 and $15.00 per hour

More than $15.00 per hour? ..................
Approximately $30,000 a year or more 

_____% Earned more than $15.00 per hour

____ Hours

Section D – BUSINESS CHARACTERISTICS

Mark (X) only one.

___ In operation  (SKIP to Question 2a)

___ Temporarily or seasonally inactive  (SKIP to Question 2a)

___ Ceased operation  (Continue with Question 1b)

___ Sold or leased to another operator  (Continue with Question 1b)

Enter two digit numeric responses
Example: January 1999 – 01 1999

_____ Mo.   19____ Yr.

See Definition Sheet included with this package for explanation of benefits.

Mark (X) all that apply. 

___ Paid vacation

___ Paid sick leave

___ Life insurance

___ Disability insurance

___ Retirement/pension plans

___ Medical savings accounts (MSAs)

___ Flexible spending accounts

___ Flexible benefit plan (Cafeteria Plan) If marked, continue with Question 2b, otherwise SKIP to Question 3.

___ None of the above

$__________ Flexible benefit plan value

Mark (X) only one.

___ S corporation

___ Corporation

___ Partnership

___ Sole proprietorship

___ Government (Federal, state, or local)

___ Joint venture or cooperative

___ Yes

___ No

If more than one apply, mark the category which generates the most revenue.

 Mark (X) only one.

___ Retail trade

___ Personal services (e.g., beauty shops, dry cleaners) 

___ Business services (e.g., advertising, computer processing) 

___ Other services (e.g., legal and health services) 

___ Manufacturing

___ Wholesale trade 

___ Finance, insurance, or real estate 

___ Transportation, communication, electric, gas, or sanitary services

___ Construction 

___ Agriculture or forestry 

___ Mining 

If your organization operates at more than one location, enter the number of years the parent company has been in business.

_________ Approximate number of years in business

If your organization DID NOT offer health insurance coverage to its employees in 1999, SKIP to Page 8, Section F.

Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS

Estimates are acceptable.

Please complete questions 1–3 for this location ONLY.

1. What was the total annual cost of coverage for ALL hospital and/or physician plans offered AT THIS LOCATION in 1999?

Include both employer and employee contributions.

Include the total cost of coverage for all active employees at the location identified on the cover sheet. 

$_________________ Annual cost for hospital and/or physician plans

Do not include single services covered under a comprehensive health plan.

Report on single service insurance plans only.

Mark (X) all that apply.

___ Dental - Continue with Question 2b
___ Vision - Continue with Question 2b
___ Prescription drugs - Continue with Question 2b
___ Long-term care - Continue with Question 2b
___ No optional coverage – SKIP to Question 3a

Yes – Continue with Question 3b
No –   SKIP to Question 4 

Mark (X) only one.

___ Less than 2 weeks
___ weeks to less than 1 month
___ Until the first day of the next month
___ 1–3 months
___ More than 3 months

4. In 1999, did your organization provide health insurance to any employees who retired from your
organization?

If your organization did not have retirees, mark "No."

___ Yes – Continue with Question 5a
___ No - SKIP to Page 8, Section F
___ Don’t know - SKIP to Page 8, Section F

___ No 
___ Yes

________ Retiree-only plans

OR

___ None

A portable plan allows the retiree to obtain care in almost all localities within the country.

___ No
___ Yes

Section E – GENERAL HEALTH COVERAGE CHARACTERISTICS – Continued

__________ Retirees covered by insurance

For retirees, if premiums vary, report for a family of two.

$__________ Family coverage premium

Section F – PERSON COMPLETING THIS QUESTIONNAIRE

*** PLEASE NOTE ***

If your organization offered health insurance, please complete Section F and the attached MEPS-10(S), Plan Information Questionnaire for each plan offered.

If your organization DID NOT offer health insurance, please complete Section F and END the form.

Date (Month/Day/Year)

Signature  

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