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

2013 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE

OMB No. 0935-0110: Approval Expires 12/31/2014
FORM MEPS-10(S) (03-07-2013)

INSTRUCTIONS

REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2013 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, answer for the plan specified. Otherwise, complete this Plan Information Questionnaire for the plan with the largest (or next largest) enrollment of active employees.

  1. For 2013, what was the name of the health insurance plan with the largest (or next largest) enrollment of ACTIVE employees?

    Examples:
    Name of Plan ____________________________________



  2. Which type of health care provider arrangement was available through this plan?

    Exclusive providers - Enrollees must go to 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.

    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.

    _____ Exclusive providers (Examples: Most HMO, IPA, and EPO-type plans)
    _____ Any providers (Examples: Most fee-for-service plans)
    _____ Mixture of preferred and any providers (Examples: Most PPO and POS-type plans)



  3. 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.

    _____ Yes
    _____ No
    _____ Don't know



  4. Was this plan offered through a union or a trade association?

    _____ Union
    _____ Trade association
    _____ Neither



  5. 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 enrollees’ medical expenses.

    Self-insured - Your organization assumes the risk for the enrollees’ medical expenses and may charge a premium to the employees. This plan may be administered by a third party and may employ supplemental stop-loss insurance to limit unanticipated losses.

    _____ Purchased - SKIP to Question 7a
    _____ Self-insured - Continue with Question 6a
    _____ Don't know - SKIP to Question 7a

SELF-INSURED PLAN INFORMATION

Complete questions 6a-c if this plan was self-insured.
  1. a.  Did your organization employ a third party administrator (TPA) or purchase administrative services only (ASO) from an insurer for this self-insured plan?

    _____ Yes - Used a TPA or ASO
    _____ No - Self-administered the plan

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

    _____ Yes
    _____ No - SKIP to Question 7a

    c.  What was the specific stop-loss amount per employee?

    $__________.00

ACTIVE ENROLLMENT

Estimates are acceptable for all enrollment figures.

  1. a.  How many ACTIVE employees at this location were ENROLLED in this plan during a typical pay period in 2013?

    Include full-time, part-time, temporary, and seasonal employees.

    Exclude former employees, leased or contract workers and retirees.

    __________ Active employees enrolled in plan

    b.  How many of these ACTIVE employees were ENROLLED in SINGLE coverage during a typical pay period in 2013?

    __________ Active employees enrolled in single coverage

    EMPLOYEE-PLUS-ONE coverage is health insurance coverage for an employee-plus-spouse or an employee-plus-child(ren) AT A LOWER PREMIUM LEVEL than family coverage.

    c.  If your organization offered EMPLOYEE-PLUS-ONE coverage, how many ACTIVE employees were ENROLLED during a typical pay period in 2013?

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

    __________ Active employees enrolled in employee-plus-one coverage

    d.  How many ACTIVE employees were ENROLLED in FAMILY (i.e., not single or employee-plus-one) coverage during a typical pay period in 2013?

    __________ Active employees enrolled in family coverage

COBRA ENROLLMENT

  1. How many FORMER employees were ENROLLED in this plan, excluding retirees, through COBRA or state continuation-of-benefits laws during a typical pay period in 2013?

    __________ Former employees enrolled in plan, excluding retirees

PLAN PREMIUMS

Report for TYPICAL situations and enrollees. If premium 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 2013.

If there is an HSA or HRA associated with this plan, include any employer contributions to an HSA or HRA account in the employer contribution to the premium.

SINGLE COVERAGE

  1. a.  Was SINGLE coverage offered under this plan?

    _____ Yes - Continue with Question 9b
    _____ No - SKIP to Question 10a

    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

    e.  The amounts reported in questions 9b-d are based on which one of the following time periods?

    Mark (X) only one.

    _____ Weekly
    _____ Every 2 weeks
    _____ Monthly
    _____ Quarterly
    _____ Yearly

EMPLOYEE-PLUS-ONE COVERAGE

If employee-plus-one premiums were different for employee-plus-child(ren) and employee-plus-spouse coverages, report for employee-plus-one-child. If premiums varied for other reasons, report for a TYPICAL employee.

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

    _____ Yes - Continue with Question 10b
    _____ No - SKIP to Question 11a

    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

    e.  The amounts reported in questions 10b-d are based on which one of the following time periods?

    Mark (X) only one.

    _____ Weekly
    _____ Every 2 weeks
    _____ Monthly
    _____ Quarterly
    _____ Yearly

FAMILY COVERAGE

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

  1. a.  Was FAMILY coverage offered under this plan?

    _____ Yes - Continue with Question 11b
    _____ No - SKIP to Question 12a

    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.  The amounts reported in questions 11b-d are based on which one of the following time periods?

    Mark (X) only one.

    _____ Weekly
    _____ Every 2 weeks
    _____ Monthly
    _____ Quarterly
    _____ Yearly

GENERAL PREMIUM INFORMATION

  1. a.  Did the PREMIUMS for this insurance plan vary by any of these characteristics?

    Age: .................................. ____ Yes, ____ No, ____ Don't know
    Gender: ............................. ____ Yes, ____ No, ____ Don't know
    Wage or salary levels: ........ ____ Yes, ____ No, ____ Don't know
    Smoker/Non-smoker status: ____ Yes, ____ No, ____ Don't know
    Other:  ............................... ____ Yes, ____ No, ____ Don't know

    b.  Did the amount an EMPLOYEE CONTRIBUTED toward his/her own coverage vary by any of these employee characteristics?

    Do not include internal incentvie programs that do not impact contributions..

    Hours worked: .......................................... ____ Yes, ____ No, ____ Don't know
    Union status: .............................................. ____ Yes, ____ No, ____ Don't know
    Wage or salary level: .................................. ____ Yes, ____ No, ____ Don't know
    Occupation: ................................................ ____ Yes, ____ No, ____ Don't know
    Length of employment: ................................ ____ Yes, ____ No, ____ Don't know
    Participation in a fitness/weight loss program: ____ Yes, ____ No, ____ Don't know
    Participation in a smoking cessation program: ____ Yes, ____ No, ____ Don't know
    Other: .......................................................... ____ Yes, ____ No, ____ Don't know

INDIVIDUAL DEDUCTIBLES

  1. a.  Did this plan have a deductible?

    Deductible - Predetermined amount which must be paid by an individual before the plan will reimburse for covered services.

    Many HMOs do not have a deductible.

    _____ Yes - Continue with Question 13b
    _____ No - SKIP to Question 16a

    b.  What was the annual deductible an individual paid?

    Report "IN-NETWORK" deductibles (if applicable).

    If separate deductibles apply, enter physician care and hospital care amounts in appropriate boxes.

    If deductible is per overnight hospital stay, it is not an annual deductible and should be reported under Question 16b.

    DO NOT report COPAYMENTS or individual or family out-of-pocket maximums here.

    $__________.00 Individual annual deductible

    OR

    Separate deductibles for:
    $__________.00 Physician care
    $__________.00 Hospital care

FAMILY DEDUCTIBLES

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

    _____ Yes - Continue with Question 14b
    _____ No - SKIP to Question 14c
    _____ Family coverage not offered - SKIP to Question 15

    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

    c.  What was the total annual deductible a family paid?

    Report for a family of four.

    $__________.00 Total annual family deductible

HEALTH SAVINGS ACCOUNT (HSA)

  1. If the deductibles you reported in questions 13 and 14 were $1,250 or higher for single coverage and $2,500 or higher for family coverage, did your organization contribute to a Health Savings Account (HSA) for the plan enrollees in 2013?

    _____ Yes, contributed to an HSA
    _____ No, did not contribute to an HSA
    _____ Don't know

PAYMENTS

  1. a.  Was hospital care covered under this plan?

    _____ Yes - Continue with Question 16b
    _____ No - SKIP to Question 16c

    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?

    Out-of-pocket expense - Those costs paid directly by the enrollee.

    Some plans may have both a dollar copayment and a percentage coinsurance.

    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

    _____ Per day
    _____ Per stay

    AND / OR

    __________% Coinsurance paid by enrollee

    c.  Was physician care covered under this plan?

    _____ Yes - Continue with Question 16d
    _____ No - SKIP to Question 17

    d.  How much and/or what percentage of the total bill did an enrollee pay out-of-pocket for an office visit after any annual deductible was met?

    Out-of-pocket expense - Those costs paid directly by the enrollee.

    Some plans may have both a dollar copayment and a percentage coinsurance.

    Report for an "in-network"/participating general practitioner during normal office hours.

    $__________.00 Copayment paid by enrollee for office visit

    AND / OR

    __________% Coinsurance paid by enrollee



  2. Were prescription drugs covered under this health plan?

    _____ Yes
    _____ No - SKIP to Question 19a
    _____ Don't know - SKIP to Question 19a



  3. How much and/or what percentage did an enrollee pay out-of-pocket for the lowest tier of prescription drug coverage?

    Report for the least expensive pharmacy available to the enrollee under the plan, excluding any mail-order programs.

    Lowest cost to enrollee
    $________.00 Copayment

    AND / OR

    _________% Coinsurance


Include all copayments, coinsurance and deductibles.

  1. a.  What was the MAXIMUM ANNUAL out-of-pocket expense for an individual?

    Out-of-pocket expense - Those costs paid directly by the enrollee.

    This is often referred to as a catastrophic limit.

    $_________.00

    OR

    _____ No individual maximum

    b.  What was the MAXIMUM ANNUAL out-of-pocket expense for a family of four?

    $__________.00

    OR

    _____ No family maximum

PLAN CHARACTERISTICS

  1. Could this plan have refused to cover persons with pre-existing medical or health conditions?

    _____ Yes
    _____ No



  2. Did this plan have a policy requiring a waiting period before covering pre-existing conditions?

    _____ Yes
    _____ No



  3. Which of the services listed were covered by this plan?

    Chiropractic care .......................  _____ Yes,   _____ No,   _____ Don't know
    Routine vision care for children ...  _____ Yes,   _____ No,   _____ Don't know
    Routine vision care for adults ......  _____ Yes,   _____ No,   _____ Don't know
    Routine dental care for children .... _____ Yes,   _____ No,   _____ Don't know
    Routine dental carefor adults ........ _____ Yes,   _____ No,   _____ Don't know
    Mental heath care ........................ _____ Yes,   _____ No,   _____ Don't know
    Substance abuse treatment ........... _____ Yes,   _____ No  , _____ Don't know



  4. Was this a grandfathered health plan as defined by the Affordable Care Act?

    See the definition sheet included with this package for an explanation.

    _____ Yes
    _____ No
    _____ Don't know

*** PLEASE NOTE ***

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, up to four plans.