2014 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY

OMB No. 0935-0110: Approval Expires 11/30/2016
Form MEPS-10 (03-05-2014)

 


 (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

INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address:
https://econhelp.census.gov/mepsgov
Your Survey Key to access the Internet form is:

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

  1. Please report for the location identified on the cover sheet, unless otherwise specified.

  2. Please report data for 2014.

  3. Estimates are acceptable.

  4. For an explanation of unfamiliar terms, refer to the definition sheet included with this package.

  5. Unless otherwise specified, respond for ACTIVE employees.

  6. Please retain a completed copy of this form for your records.

  7. If you have any questions or need assistance in completing the questionnaire, please call __________

Collection of this information is authorized under Section 913 of the Public Health Service Act (Title 42 United States Code, Section 299b-2). Section 9 of Title 13, United States Code (the U.S.Census Bureau Statute), ensures that the information you report to us will be strictly confidential. It may be seen only by the individuals sworn to uphold U.S. Census Bureau confidentiality andmay be used only for statistical purposes.

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 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. If the enclosed mailing envelope has been misplaced, please use address on front page of form to return questionnaire.

Section A - NUMBER OF PLANS

Respond for ACTIVE employees only.

  1.   Did your organization make available or contribute to the cost of any health insurance plans for its active employees at this location in 2014?

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

    _____ Yes - Continue with Question 2
    _____ No - SKIP to Section B



  2.   How many different health insurance choices did your organization make available or contribute to for its active employees at this location during the 2014 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 from the same insurance company count as TWO plans.

    __________ Health insurance plan choices at this location

Section B - PRIOR YEAR OFFERING

  1.   In 2013, did your organization offer health insurance as a benefit to its ACTIVE employees at this location?

    _____ Yes - Offered
    _____ No - Did not offer
    _____ Don't know

Section C - EMPLOYMENT CHARACTERISTICS

Estimates are acceptable for all employment, eligibility, and enrollment figures.

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

Exclude former employees, leased or contract workers and retirees.

  1.   What was the total number of employees your organization had at ALL locations for a TYPICAL pay period in 2014?

    __________ Employees at all locations


Complete questions 2-8 for THE LOCATION listed on the cover sheet.

  1. a.  How many employees were on your organization’s payroll AT THIS LOCATION for a TYPICAL pay period in 2014?

    _________ All employees at this location

    If your organization did not offer health insurance in 2014, SKIP to Question 3a.

    b.  How many of these employees were ELIGIBLE for at least one health plan through your organization?

    _________ Eligible employees

    c.  How many of these employees were ENROLLED in ANY health plan through your organization?

    _________ Enrolled employees



  2. a.  For the same TYPICAL pay period in 2014, how many of the employees reported in 2a worked part-time?

    __________ Part-time employees

    If your organization did not offer health insurance in 2014, SKIP to Question 4.

    b.  How many of these part-time employees were ELIGIBLE for at least one health plan through your organization?

    __________ Eligible part-time employees

    c.  How many of these part-time employees were ENROLLED in ANY health plan through your organization?

    __________ Enrolled part-time employees


  3.   How many of the employees reported in Question 2a worked less than 30 hours per week?

    _____ Employees worked less than 30 hours
    _____ No employees worked less than 30 hours



  4.   Is the information you provided in questions 2, 3 and 4 above for the location listed on the cover sheet OR did you provide information for multiple locations?

    _____ Information for specified location
    _____ Information for multiple locations

    If your organization did not offer health insurance in 2014, SKIP to Question 7a.


  5.   If your organization offered health insurance, what is the minimum number of hours per week that an employee had to work in order to be eligible for health insurance?

    _____ Minimum Hours worked per week to be eligible
    _____ No minimum number of hours required


Provide information for a TYPICAL pay period in 2014.

Estimates are acceptable.

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

  1. a.  Approximately what percentage of the employees at this location were union members?

    _________ % Union members
    _________ No union members

    b.  Approximately what percentage of the employees at this location were women?
    If none, enter "0".

    __________% Women employees

    c.  Approximately what percentage of the employees at this location were 50 years old or older?
    If none, enter "0".

    __________% Employees 50 years old or older

    d.  For the employees at this location in 2014, approximately what percentage earned -
    If none, enter "0".

    Less than $11.50 per hour?
    Approximately $24,000 a year or less
    ____% Earned less than $11.50 per hour

    Between $11.50 and $27.50 per hour?
    Approximately $24,000 to $57,000 a year
    ____ % Earned between $11.50 and $27.50 per hour

    More than $27.50 per hour?
    Approximately $57,000 a year or more
    ____% Earned more than $27.50 per hour


  2.   For the employees at this location in 2014, approximately how many earned more than $42.50 per hour?
    Approcimately $88,000 a year or more

    _____ Number of employees that earned more than $42.50 per hour

Section D - FRINGE BENEFITS CHARACTERISTICS

  1.   Did your organization offer the following fringe benefits to its employees at this location in 2014?

    Paid vacation ............................     _____ Yes     _____ No     _____ Don't know
    Paid sick leave ..........................     _____ Yes     _____ No     _____ Don't know
    Life insurance ...........................     _____ Yes     _____ No     _____ Don't know
    Disability insurance ...................     _____ Yes     _____ No     _____ Don't know
    Retirement/pension plans .........      _____ Yes     _____ No     _____ Don't know



  2.   Did your organization offer any of these tax-advantaged benefits to its employees at this location in 2014?

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

    These benefits are also known as Section 125 Cafeteria plans.

    Employee contributions to health insurance made on a pre-tax basis
    _____ Yes     _____ No     _____ Don't know

    Flexible SPENDING Accounts (FSA) For Healthcare
    _____ Yes     _____ No     _____ Don't know

    Flexible Benefits Plans
    Full cafeteria plan that offers employees a set of benefits from which to choose.
    _____ Yes     _____ No     _____ Don't know

If your organization DID offer health insurance coverage to its employees in 2014, continue to Section E.

If your organization DID NOT offer health insurance coverage to its employees in 2014, SKIP to Section G.

Section E - SMALL BUSINESS

Complete only if your organization offered insurance and has 50 employees or fewer OR has 50 full-time equivalent employees or fewer at all locations (see definition MEPS 20-D). Otherwise, SKIP to Section F.

  1.   Did your organization offer health insurance through a Small Business Health Options Program (SHOP) exchange or marketplace in your state?

    _____ Yes
    _____ No - SKIP to Section F
    _____ Don't know - SKIP to Section F



  2.   Will your organization claim a Small Business Health Care Tax

    Credit on its 2014 federal taxes?

    A small employer may be eligible for this credit on its fereral income taxes if: 1.) if has fewer than 25 full-time equivalent employees, 2.) pays an average wage of less than $50,000 per year, AND 3.) pays at least half of the health insurance premiums for its employees. .

    _____ Yes
    _____ No
    _____ Organization not eligible
    _____ Don't know

Section F - GENERAL HEALTH COVERAGE CHARACTERISTICS

  1. a.  Which of the listed optional coverage services, if any, did your organization offer to its ACTIVE employees at this location in 2014 at a premium SEPARATE from the comprehensive health plan premium?

    Report single service insurance plans only.

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

    Long-term care insurance helps cover the cost of institutional and home care required by the chronically ill or disabled.

    Mark (X) all that apply.

    _____ Dental - Continue with Question 1b
    _____ Vision - Continue with Question 1b
    _____ Prescription drugs - Continue with Question 1b
    _____ Long-term care - Continue with Question 1b
    _____ No optional coverage - SKIP to Question 2a

    b.  What was the total amount paid for optional coverage for all ACTIVE employees during a TYPICAL MONTH at this location in 2014?

    Include both employer and employee contributions.

    $_______________.00 Monthly optional coverage cost



  2.   For 2014, did your organization impose a waiting period before new employees could be covered by health insurance?

    _____ Yes
    _____ No



  3.   Did your organization provide any financial compensation or incentives to employees if they did not elect to receive health insurance coverage?

    _____ Yes
    _____ No
    _____ Don't know



  4.   Were employees' SPOUSES eligible for health insurance coverage through your organization?

    _____ All - all spouses eligible
    _____ Limited - Only spouses who weren't eligible through their own employer
    _____ No - no spouses eligible
    _____ Don't know



  5. a.  Did your organization offer health insurance coverage to UNMARRIED domestic partners of the SAME sex?

    _____ Yes
    _____ No
    _____ Don't know

    b.  Did your organization offer health insurance coverage to UNMARRIED domestic partners of the OPPOSITE sex?

    _____ Yes
    _____ No
    _____ Don't know


Section G - RETIREE HEALTH COVERAGE CHARACTERISTICS

Please complete questions 1-5 for ALL LOCATIONS.

Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws. See the definition sheet included with this package for an explanation of these terms.

  1.   Did your organization provide health insurance coverage to any person who retired in 2014 OR BEFORE, or to any of their survivors?

    If COBRA was the only coverage offered, mark “No.”

    _____ Yes - Continue with Question 2
    _____ No - SKIP to Section H
    _____ Don't Know - SKIP to Section H



  2.   In a typical month, how many retirees were enrolled in health insurance through your organization at all of its locations?

    __________ Number of retirees enrolled

UNDER 65 YEARS OF AGE

Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws.

If this was a Self-Insured Plan, report the premium equivalent.

  1. a.  Were any of the enrolled retirees, reported in Question 2, under 65 years of age?

    _____ Yes - Continue with Question 3b
    _____ No - Skip to Question 4a

    b.  In a typical month, how many retirees under 65 years of age were enrolled in health insurance through your organization at all of its locations?

    __________ Number of retirees under 65 enrolled in health insurance

    c.  What percentage of these retirees were ENROLLED in SINGLE coverage?

    __________% Retirees under 65 enrolled in single coverage

    d.  For a typical plan in 2014, how much did the EMPLOYER contribute toward the monthly plan premium for one typical retiree with SINGLE coverage?

    $__________.00 Employer contribution for single premium

    e.  For this same plan, what was the TOTAL monthly premium for this typical retiree with SINGLE coverage?

    $__________.00 Total single premium

    f.  For a typical plan in 2014, how much did the EMPLOYER contribute toward the monthly plan premium for one typical retiree with FAMILY coverage?

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

    $__________.00 Employer contribution for family premium

    g.  For this same plan, what was the TOTAL monthly premium for this typical retiree with FAMILY coverage?

    $__________.00 Total family premium

    h.  Did a typical plan provide coverage for outpatient prescription drugs for retirees under 65 years of age?

    _____ Yes
    _____ No
    _____ Don't Know


AGE 65 YEARS OR OVER

Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws.

If this was a self-insured plan, report the premium equivalent.

  1. a.  Were any of the enrolled retirees, reported in Question 2, 65 years of age or over?

    _____ Yes - Continue with Question 4b
    _____ No - Skip to Question 5a

    b.  In a typical month, how many retirees 65 years of age or over were enrolled in health insurance through your organization at all of its locations?

    __________ Number of retirees 65 or over enrolled in health insurance

    c.  What percentage of these retirees were ENROLLED in SINGLE coverage?

    __________% Retirees 65 or over enrolled in single coverage

    d.  For a typical plan in 2014, how much did the EMPLOYER contribute toward the monthly plan premium for one typical retiree with SINGLE coverage?

    $__________.00 Employer contribution for single premium

    e.  For this same plan, what was the TOTAL monthly premium for this typical retiree with SINGLE coverage?

    $__________.00 Total single premium

    f.  For a typical plan in 2014, how much did the EMPLOYER contribute toward the monthly plan premium for one typical retiree with FAMILY coverage?

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

    $__________.00 Employer contribution for family premium

    g.  For this same plan, what was the TOTAL monthly premium for this typical retiree with FAMILY coverage?

    $__________.00 Total family premium

    h.  Did a typical plan provide coverage for outpatient prescription drugs for retirees 65 years of age or over?

    _____ Yes
    _____ No
    _____ Don't Know


NEW RETIREES

For questions 5a through 5c, NEW RETIREES refers only to persons who retired from your organization in 2014.

Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws.

  1. a.  Did your organization offer health insurance to any NEW RETIREES?

    _____ Yes - Continue with Question 5b
    _____ No - SKIP to Section H
    _____ Don't know - SKIP to Section H

    b.  Were NEW RETIREES under 65 years of age eligible for health insurance?

    _____ Yes
    _____ No
    _____ Don't know

    c.  Were NEW RETIREES 65 years of age or over eligible for health insurance?

    _____ Yes
    _____ No
    _____ Don't know

Remarks

 

 

Section H - PERSON COMPLETING THIS QUESTIONNAIRE

*** PLEASE NOTE ***

If your organization offered health insurance, please complete Section H and an attached MEPS-10(S), Plan Information Questionnaire, for each plan offered up to four plans.

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


Name (Please Print) _________________________________________________

Title (Please Print) _________________________________________________

Signature _________________________________________________

Date (Month/Day/Year) : ____ (MM) ____ (DD)  20____ (YY)

Telephone number ( ___ ) ___ - ____

Extension ______

Fax ( ___ ) ___ - _____

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS