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

Medical Expenditure Panel Survey - Insurance Component
 HEALTH INSURANCE  COST STUDY
Government Unit Questionnaire

Section C – RETIREE HEALTH COVERAGE CHARACTERISTICS

______  Yes – Continue with Question 2
______  No – SKIP to Section D
______  Don’t know  – SKIP to Section D

____  Yes

____  No

3. How many RETIREE-ONLY hospital and/or physician plan choices did your government unit offer in 2000?

Do not include plans for which ACTIVE employees were eligible.

 _______Retiree-only plans

___ None

UNDER 65 YEARS OF AGE

____  Yes - Continue with Question 4b

____  No - SKIP to Question 5a

__________ Total retirees under 65 covered by insurance

________% Retirees under 65 enrolled in employee-only coverage

$____________ Employer contribution for employee-only premium

$_____________ Total employee-only premium

For retirees, if premium varies by family size, report for a family of two.

$___________ Employer contribution for family premium

$______________ Total family premium

65 YEARS AND OVER

5a. Were retirees 65 years and over eligible to receive health insurance in 2000?

____  Yes - Continue with Question 5b

____  No - SKIP to Section D, Question 1a

__________ Total retirees 65 years and over covered by insurance

________% Retirees 65 years and over enrolled in employee-only coverage

$____________ Employer contribution for employee-only premium

$_____________ Total employee-only premium

For retirees, if premium varies by family size, report for a family of two.

$___________ Employer contribution for family premium

$______________ Total family premium

Section D – HEALTH COVERAGE CHARACTERISTICS

Complete section D if your government unit made insurance available to its ACTIVE employees in 2000.

Estimates are acceptable.

1a. What was the total annual cost of coverage for ALL hospital and/or physician plans offered through THIS GOVERNMENT UNIT in 2000?

Include both employer and employee contributions.

Include the total cost of coverage for all ACTIVE employees. 

$_________________ Annual cost for hospital and/or physician plans

b.  What percentage of the total annual cost was contributed by the employer?

_________________% Employer contribution

2a. Which of the listed optional coverage services, if any, did your government unit offer to its ACTIVE
employees in 2000 at a premium SEPARATE from the comprehensive health plan premium?

Report on single service insurance plans only.

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

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

Include both employer and employee contributions.

$________ Optional coverage cost

3a. For 2000, did your government unit impose a waiting period before new employees could be covered by health insurance?

Yes – Continue with Question 3b
No –  SKIP to Section E

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

Section E – EMPLOYMENT CHARACTERISTICS

1a. How many ACTIVE employees were ELIGIBLE for at least one health plan through your government unit IN 2000?

____________ Eligible employees

___________ Enrolled employees

2a. Did your government unit have any part-time employees in 2000? 

____  Yes – Continue with Question 2b

____  No –  SKIP to Question 3

____  Don't know –  SKIP to Question 3

If your government unit did not offer health insurance in 2000, SKIP to Section F.

__________ Eligible part-time employees

__________ Enrolled part-time employees

3. Did your government unit offer health insurance to its temporary or seasonal employees in 2000? 

Mark (x) only one.

____  Yes 

____  No 

____  No temporary or seasonal employees 

____  Don't know 

Section F – FRINGE BENEFIT CHARACTERISTICS

1a. Which of the following fringe benefits did your government unit offer  in 2000?

For the explanation of unfamiliar terms, refer to the  Definition Sheet included with this package.

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 1b, otherwise SKIP to Section G.

___ None of the above, SKIP to Section G

$__________ Annual flexible benefit plan value

Section G – EMPLOYEE CHARACTERISTICS

Provide information for a typical pay period in 2000.

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

If none, enter "0" 

1a. What percentage of the total employees at this government unit were women?

______% Women employees

______% Employees 50 years old or older

______% Union members

Less than $9.50 per hour? . . . . . . . . . . . . . . . .
Approximately $19,800 a year or less
_________ % Earned less than $9.50 per hour

Between $9.50 and $21.00 per hour? . . . . . .
Approximately $19,800 to $43,700 a year
_________ % Earned between $9.50 and $21.00 per hour

More than $21.00 per hour? . . . . . . . . . . . . . .
Approximately $43,700 a year or more
_________ % Earned more than $21.00 per hour

2. How many hours per week must an employee work to be considered full-time at this government unit?

__________ Hours

Section H – PERSON COMPLETING THIS QUESTIONNAIRE