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
PLAN INFORMATION QUESTIONNAIRE

OMB No. 0935-0110: Approval Expires 11/30/2018
Form MEPS-11(S) (03-29-2016)

INSTRUCTIONS

The MEPS-11(S), Plan Information Questionnaire, is to be completed for ALL health insurance plans offered in 2016 AT THIS GOVERNMENT UNIT. Please use photocopies of this MEPS-11(S) form if sufficient copies were not included in this reporting package.

GENERAL PLAN INFORMATION

Begin with the plan having the largest enrollment and proceed through to the plan with the smallest enrollment of ACTIVE employees.

Please photocopy this MEPS-11(S) questionnaire if additional forms are needed.

  1.   For 2016, what was the name of the health insurance plan with the largest (or next largest) enrollment of ACTIVE employees?

    Examples:
    • Blue Cross Blue Shield, High Option
    • Option A
    • Aetna HMO

    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 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 government unit assumes the risk for the enrollees’ medical expenses and may charge a
    premium to 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 6
    _____ Self-insured - Continue with Question 5a
    _____ Don't know - SKIP to Question 6

SELF-INSURED PLAN INFORMATION

Complete questions 5a-c if this plan was self-insured.

  1. a.  Did your government unit 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 government unit purchase stop-loss coverage for this plan?

    (see definition sheet MEPS-20(D) for more information)

    _____ Yes
    _____ No- SKIP to Question 6
    c.  What was the specific stop-loss amount PER EMPLOYEE?

    $__________.00

ACTUARIAL VALUE OR METAL LEVEL

  1.   What was this plan’s actuarial value OR metal level?

    Actuarial Value is the percentage of medical expenses paid by the plan rather than out-of-pocket for a typical group of enrollees.

    Metal Levels are labels for insurance plans that describe the level of benefits and cost-sharing provisions.

    Actuarial Value:

    _______ % of medical expenses paid by plan

    OR

    Metal Level:

    ____ Bronze
    ____ Silver
    ____ Gold
    ____ Platinum
    ____ N/A, Grandfathered Plan


    ____ Don't know


ACTIVE ENROLLMENT

Estimates are acceptable for all enrollment figures.

  1. a.  How many ACTIVE employees were ENROLLED in this plan at this government unit during a typical pay period in 2016?

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

    Exclude retirees, former employees, leased or contract workers.

    __________ Active employees enrolled in plan

    b.  How many of those ACTIVE employees were ENROLLED in SINGLE coverage during a typical pay period in 2016?

    __________ Active employees enrolled in single coverage

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

    c.  If your government unit offered EMPLOYEE-PLUS-ONE coverage, how many ACTIVE employees were ENROLLED during a typical pay period in 2016?

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

    __________ Active employees enrolled in employee-plus-one coverage

    d.  How many of those ACTIVE employees were ENROLLED in FAMILY (not single or employee-plus-one) coverage during a typical pay period in 2016?

    __________ Active employees enrolled in family coverage

PHSA (COBRA) ENROLLMENT

  1.   How many FORMER employees were ENROLLED in this plan, excluding retirees, through PHSA (COBRA) or state continuation-of-benefits laws during a typical pay period in 2016?

    __________ 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 government unit/employee contributions and total premium for the same period in 2016.

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 GOVERNMENT UNIT 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 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 GOVERNMENT UNIT contribute toward the plan premium of one typical employee with EMPLOYEE-PLUS-ONE coverage?

    $__________.00 Government unit 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 GOVERNMENT UNIT contribute toward the plan premium of one typical employee with FAMILY coverage?

    $__________.00 Government unit 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 11 b-d are based on which one of the following time periods?

    Mark (X) only one.

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

    f.  Did the TOTAL premium reported earlier for FAMILY coverage vary depending on the number of family members covered by the plan?

    _____ Yes
    _____ No
    _____ Don't know

GENERAL PREMIUM INFORMATION

  1. a.  Did the TOTAL premium reported earlier for SINGLE coverage vary by the age of the employee enrolled in the plan?

    ____ Yes
    ____ No
    ____ Don't know

    b. Did older EMPLOYEES contribute more toward their SINGLE coverage premium than younger employees?

    ____ Yes
    ____ No
    ____ Don't know
    ____ Family coverage not offered

    c.  Did the amount individual EMPLOYEE contributed toward their SINGLE coverage premium vary by any of these characteristics?

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

    Participation in a fitness/weight loss program: ____ Yes, ____ No, ____ Don't know
    Participation in a smoking cessation program: ____ Yes, ____ No, ____ Don't know
    Wellness / Health monitoring: ........................____ 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 16

    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 17b.

    DO NOT report COPAYMENTS or individual or family maximums here.


    If prescription drugs have a separate deductible, it should be reported under Question 19c.


    $__________.00 Individual annual deductible

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)

Complete only if the deductibles for this plan were $1,300 or higher for single coverage and/or $2,600 or higher for family coverage, otherwise skip to Question 16.

  1.   Did your government unit contribute to a Health Savings Account (HSA) for the plan enrollees in 2016?

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

HEALTH REIMBURSEMENT ARRANGEMENT (HRA)

  1.   Did your government unit offer an HRA associated with this plan in 2016?

    An employer can offer a Health Reimbursement Arrangement (HRA) by setting up an account to reimburse employees for medical expenses not covered by health insurance.

    HRAs are NOT Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs). See definition sheet MEPS-20(D) for more information.

    _____ Yes
    _____ No
    _____ Don't know

PAYMENTS

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

    _____ Yes - Continue with Question 17b
    _____ No - SKIP to Question 18a

    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



  2. a.  Was physician care covered under this plan?

    _____ Yes - Continue with Question 19b
    _____ No - SKIP to Question 19a

    b.  How much and/or what percentage of the total bill did an enrollee pay out-of-pocket for a General Practitioner office visit, with a participating physician, after any annual deductible was met?

    Out-of-pocket expense - 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, excluding preventive care visits.


    $__________.00 Copayment paid by enrollee for office visit

    AND / OR

    __________% Coinsurance paid by enrollee

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

    Report for an "in-network" / participating specialist.


    $__________.00 Copayment paid by enrollee for Specialist Physician office visit

    AND / OR

    __________% Coinsurance paid by enrollee



  3. a.  Were prescription drugs covered under this health plan?

    _____ Yes - Continue with Question 19b
    _____ No - SKIP to Question 20a
    _____ Don't know - SKIP to Question 20a

    b.  Did this plan have a SEPARATE ANNUAL deductible that applies only to prescription drugs?

    _____ Yes - Continue with Question 19c
    _____ No - SKIP to Question 19d
    _____ Don't know - SKIP to Question 19d

    c.  What was the ANNUAL deductible for prescription drugs for single coverage in this plan?

    Report "in-network" deductibles (if applicable).

    $__________.00

    d.  How much and/or what percentage did an enrollee pay out-of-pocket for each type of prescription drug covered?

    Out-of-pocket expense - Costs paid directly by the enrollee.

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

    Generic

    $______.00 Copayment

    AND / OR

    ______% Coinsurance


    _____ Generic not covered


    Preferred brand name

    $______.00 Copayment

    AND / OR

    ______% Coinsurance


    _____ Preferred brand name not covered


    Non-preferred brand name

    $______.00 Copayment

    AND / OR

    ______% Coinsurance


    _____ Non-preferred brand name not covered


    Specialty

    Specialty drugs are prescription medications that are used to treat complex, chronic and often costly conditions.
    See definition sheet MEPS-20(D) for more information.

    $______.00 Copayment

    AND / OR

    ______% Coinsurance


    _____ Specialty not covered


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.   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 healthcare ........................ _____ Yes,   _____ No,   _____ Don't know
    Substance abuse treatment .......... _____ Yes,   _____ No,   _____ Don't know



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

    See the definition sheet MEPS-20(D) included with this package for an explanation.

    _____ Yes
    _____ No
    _____ Don't know

*** PLEASE NOTE ***

If your government unit offered only one health insurance plan, you have completed your response to this survey.

If your government unit offered MORE THAN ONE health insurance plan, please complete a Plan Information Questionnaire for each plan that was offered.

Feel free to include any health insurance brochure information you may have in your return packet or fax to 1-800-447-4615.