2015 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY

Government Questionnaire

OMB No. 0935-0110: Approval Expires 11/30/2016
Form MEPS-11(F) (03-27-2015)

 


 (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 secure web address:
econhelp.census.gov/mepsgov
Your Survey Keyto 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 government unit identified on the cover sheet.

  2. Please report data for 2015.

  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 1-888-273-3878 or visit:
    econhelp.census.gov/mepsgov

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, 5600 Fishers Lane, Rockville, MD 20857. 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

Please respond for the government unit identified on the cover sheet unless otherwise specified.

Respond for ACTIVE employees only.

  1. a.  Did your government unit make available or contribute to the cost of any health insurance plans for its ACTIVE employees in 2015?

    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 C

    b.  How many different health insurance plan choices did your government unit make available or contribute to for its ACTIVE employees during the 2015 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.

    __________ Number of Health Plans offered


PRIOR YEAR OFFERING

  1.   In 2014, did your government unit make available or contribute to the cost of any health insurance plans as a benefit to its ACTIVE emploees at this location?

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

HEALTH INSURANCE EXCHANGES

SMALL GOVERNMENT, 50 OR FEWER EMPLOYEES

Complete only if your government unit offered insurance and has 50 employees or fewer OR has 50 full-time equivalent employees or fewer at all locations (see definition MEPS-20D). Otherwise, continue with Question 4.

  1.   Did your government unit offer health insurance through a Small Business Health Options Program (SHOP) exchange or marketplace in your State in 2015?

    _____ Yes
    _____ No
    _____ Don't know

LARGE GOVERNMENT, MORE THAN 50 EMPLOYEES

Complete only if your government unit offered insurance and has more than 50 employees. Otherwise, skip to Section B, MEPS-11(S).

  1.   Did your government unit offer health insurance for active employees through a private exchange (also known as a corporate exchange) in 2015? (See definition sheet MEPS-20(D)).

    A private exchange is one created by a consulting company, insurance carrier, or other private organization, not by either a federal or state government. Private exchanges often allow employees to choose from several health insurance options offered on the exchange.

    _____ Yes
    _____ No
    _____ Don't know

Continue with Section B on MEPS-11(S)