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
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2023 AT THE LOCATION LISTED.
Please use photocopies of this MEPS-10(S) form if sufficient copies were not included in this reporting package.
If a plan name is preprinted in the Question 1 answer line, 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.
Estimates are acceptable for all enrollment figures.
For Questions 10a through 10d, if the answer is NONE, please enter "0".
Include:
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 |
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 |
Mental health care | 1 ▢ Yes | 2 ▢ No | 3 ▢ Don't know |
Substance abuse treatment | 1 ▢ Yes | 2 ▢ No | 3 ▢ Don't know |
If your organization offered only one health insurance plan, you have completed your response to this survey.
If your organization offered MORE THAN ONE health insurance plan, please complete a Plan Information Questionnaire for each plan that was offered.
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 1-800-447-4615.