OMB No.
0935-0110: Approval Expires 2/28/2005
2002
Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
Government Questionnaire
(Please correct any
errors in name, address, and ZIP Code. Enter number and street if not shown.)
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
U.S. Census Bureau
1201
East 10th Street
Jeffersonville, IN
47132-0001
OR
Fax
to 1-800-447-4613
PLEASE RETURN ENTIRE PACKAGE
WITHIN
PLEASE DO NOT REMOVE
THIS COVER SHEET
----------------------------------------------------------------------------------------------------------------------------------------------
INSTRUCTIONS
- Please report for the government unit identified
on the cover sheet.
- Please report data for the year 2002.
- Estimates are acceptable.
- For an explanation of unfamiliar terms, refer to
the Definition Sheet included with this package.
- Unless otherwise specified, respond for ACTIVE employees.
- Please retain a completed copy of this form for
your records.
- If you have any questions or need assistance in
completing the questionnaire, please call 888-273-3878.
---------------------------------------------------------------------------------------------------------------------------------------------------
We
are conducting this study under the authority of Section 913 of the Public
Health Service Act (Title 42, United States Code (U.S.C.), Section 299b-2).
Sections 924c and 308d of that Act (42 U.S.C. Section 299c-3(c) and 42 U.S.C.
Section 242m, respectively) ensure that the information you report will be
released only to authorized staff of the Census Bureau, the Agency for
Healthcare Research and Quality, and their authorized researchers and
contractors.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Paperwork Reduction Act and Burden Statements
We
expect that it will take 45 minutes, on average, to complete the basic
questionnaire. If you offered more than one plan, we expect it will take an
additional 10 minutes per plan, on average. 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 Financing,
Access, and Cost Trends, Paperwork Reduction Project 0935-0110, Agency for
Healthcare Research and Quality, Room 5030, 540 Gaither Road, Rockville, MD 20850.
Please do not mail questionnaires to this address as it will delay data
processing.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Section A – NUMBER OF PLANS
Please
respond for the government unit identified on the cover sheet unless otherwise
specified.
Respond for ACTIVE
employees only.
1a.
Did your government unit make available or contribute to
the cost of any health insurance plans for its ACTIVE employees in 2002?
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 MEPS-11(R), Section E, Question 2a
b. How many
different health insurance choices did your government unit make available or
contribute to for its ACTIVE employees during the 2002 plan year? ___________
Do not count single
service plans (optional plans) such as dental or vision.
Plans offered by
the same insurance company which offer:
·
Single,
employee-plus-one, and family coverage 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.
Continue
with Section B
Remarks
FORM MEPS-11(F) (3-4-2003)