2017 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY

OMB No. 0935-0110: Approval Expires 11/30/2018
Form MEPS-10 (03-29-2017) Draft 9

(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/meps
Your Survey Key to access the Internet form is:

If completing paper form, please RETURN TO:

U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001 OR Fax to 1-800-447-4613

PLEASE RETURN ENTIRE CONTENTS OF THIS PACKAGE WITHIN

PLEASE DO NOT REMOVE THIS COVER SHEET

INSTRUCTIONS

Please report for the location identified on the cover sheet, unless otherwise specified.
Please report data for the year 2017.
Estimates are acceptable.
For an explanation of unfamiliar terms, refer to the MEPS-20(D) Health Insurance Cost Study 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 or visit: econhelp.census.gov/meps

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 individuals sworn to uphold U.S. Census Bureau confidentiality and may 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, 5600 Fishers Lane, Mail Stop 07W41A, 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 send questionnaire to the address on the front page of this form.

NUMBER OF PLANS

Respond for ACTIVE employees only.

Did your organization make available or contribute to the cost of any health insurance plans for its ACTIVE employees at this location in 2017?

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

1 ___ Yes - Continue with 2
2 ___ No - SKIP to 3
How many different health insurance plan choices did your organization make available or contribute to for its ACTIVE employees at this location during the 2017 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

PRIOR YEAR OFFERING

In 2016, did your organization make available or contribute to the cost of any health insurance plans for its ACTIVE employees at this location?

1 ___ Yes - Offered
2 ___ No - Not offered
3 ___ Don't know

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.

What was the total number of employees your organization had at ALL locations for a TYPICAL pay period in 2017?

_________ Employees at all locations

Complete Questions 5 through 11 for THE LOCATION listed on the cover sheet.

a. How many employees were on your organization’s payroll AT THIS LOCATION for a TYPICAL pay period in 2017?

_________ All employees at this location

If your organization did not offer health insurance in 2017, SKIP to 6a.

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
a. For the same TYPICAL pay period in 2017, how many of the employees reported in Question 5a worked part-time?

If none, enter "0".

_________ Part-time employees

If your organization did not offer health insurance in 2017, SKIP to 7.

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
How many of the employees reported in Question 5a worked fewer than 30 hours per week?

_____ Employees worked fewer than 30 hours
_____ No employees worked fewer than 30 hours
Is the information you provided in Questions 5, 6 and 7 above for the location listed on the cover sheet OR did you provide information for multiple locations?

1 _____ Information for specified location
2 _____ Information for multiple locations

If your organization did not offer health insurance in 2017, SKIP to 10a.
What was 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 2017.

Estimates are acceptable.

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

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 2017, approximately what percentage earned -

If none, enter "0".

Less than $12.00 per hour?
Approximately $25,000 a year or less
____% Earned less than $12.00 per hour

Between $12.00 and $29.50 per hour?
Approximately $25,000 to $61,000 a year
____ % Earned between $12.00 and $29.50 per hour

More than $29.50 per hour?
Approximately $61,000 a year or more
____% Earned more than $29.50 per hour

100%

e. For the employees at this location in 2017, approximately how many earned more than $46.00 per hour?

Approximately $96,000 a year or more

If none, enter "0".

_____ Number of employees that earned more than $46.00 per hour

FRINGE BENEFITS CHARACTERISTICS

Did your organization offer the following fringe benefits to its employees at this location in 2017?

If Paid Time Off (PTO) is offered, mark (X) Yes for paid vacation AND paid sick leave.

Paid vacation ....................... Yes (1) ___    No (2) ___    Don't know (3) ___
Paid sick leave ..................... Yes (1) ___    No (2) ___    Don't know (3) ___
Life insurance ...................... Yes (1) ___    No (2) ___    Don't know (3) ___
Disability insurance ............. Yes (1) ___    No (2) ___    Don't know (3) ___
Retirement/pension plans ..... Yes (1) ___    No (2) ___    Don't know (3) ___
Did your organization offer any of these tax-advantaged benefits to its employees at this location in 2017?

See the definition sheet MEPS-20(D) 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 (1) ___     No (2) ___     Don't know (3) ___

Flexible SPENDING Accounts (FSA) for healthcare
Yes (1) ___     No (2) ___     Don't know (3) ___

Flexible Benefits Plans
Full cafeteria plans that offer employees a set of benefits from which to choose.
Yes (1) ___     No (2) ___     Don't know (3) ___

If your organization DID make available or contribute to the cost of any health insurance coverage for its employees in 2017, continue with 13.

If your organization DID NOT make available or contribute to the cost of any health insurance coverage for its employees in 2017, SKIP to 22.

HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS

Did your organization offer health insurance for active employees through a private exchange (also known as a corporate exchange)? (See definition sheet, MEPS-20(D).)

A private exchange is 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.

1 ___ Yes
2 ___ No
3 ___ Don't know

SMALL BUSINESS, 100 or FEWER EMPLOYEES

Complete Questions 14 through 16 only if your organization offered insurance and has 100 employees or fewer OR has 100 full-time equivalent employees or fewer at all locations (see definition sheet, MEPS-20(D).) Otherwise, SKIP to 17a.

Did your organization offer health insurance through a Small Business Health Options Program (SHOP) exchange or marketplace in your state?
1 ___ Yes
2 ___ No
3 ___ Don't know
Will your organization claim a Small Business Health Care Tax Credit on its 2017 federal taxes?

A small employer may be eligible for this credit on its federal income taxes if 1) it has fewer than 25 full-time equivalent employees, 2) pays an average wage of $50,000 or less, AND 3) pays at least half of the health insurance premiums for its employees.
1 ___ Yes
2 ___ No
3 ___ Organization not eligible
4 ___ Don't know
Did your organization use a third party, such as an insurance broker or agent, to help purchase the insurance plan(s)?

1 ___ Yes
2 ___ No
3 ___ Don't know

GENERAL HEALTH COVERAGE CHARACTERISTICS

a. Which of the listed optional coverage services, if any, did your organization offer to its ACTIVE employees at this location in 2017 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 17b
___ Vision - Continue with 17b
___ Prescription drugs - Continue with 17b
___ Long-term care - Continue with 17b
___ No optional coverage - SKIP to 18

b. What was the total amount paid for optional coverage for all ACTIVE employees during a TYPICAL MONTH at this location in 2017?

Include both employer and employee contributions.

$_______________.00 Monthly optional coverage cost
For 2017, did your organization impose a waiting period before new employees could be covered by health insurance?

1 ___ Yes
2 ___ No
3 ___ Don't know
Did your organization provide any financial compensation or incentives to employees if they did not elect to receive health insurance coverage through your organization?

1 ___ Yes
2 ___ No
3 ___ Don't know
Were employees' SPOUSES eligible for health insurance coverage through your organization?

5 ___ All spouses eligible, greater EMPLOYEE CONTRIBUTION paid if spouse eligible through own employer.
6 ___ All spouses eligible, same contribution.
7 ___ All spouses eligible, don’t know contribution.
2 ___ Limited spouses eligible, only if not offered by own employer.
3 ___ No spouses eligible.
4 ___ Don't know
Did your organization offer health insurance coverage to UNMARRIED domestic partners?

Same sex domestic partners .......... Yes (1) ___ No (2) ___ Don't know (3) ___
Opposite sex domestic partners ..... Yes (1) ___ No (2) ___ Don't know (3) ___

RETIREE HEALTH COVERAGE CHARACTERISTICS

Please complete Questions 22 through 26 for ALL LOCATIONS.

Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws. See the definition sheet MEPS-20(D) included with this package for an explanation of these terms.

Did your organization provide health insurance coverage to any person who retired in 2017 OR BEFORE, or to any of their survivors?

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

1 ___ Yes - Continue with 23
2 ___ No - SKIP to Completing This Questionnaire
3 ___ Don't Know - SKIP to Completing This Questionnaire
In a typical month, how many retirees were enrolled in health insurance through your organization at all 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.

a. Were any of the enrolled retirees, reported in Question 23, under 65 years of age?

1 ___ Yes - Continue with 24b
2 ___ No - Skip to 25a
3 ___ Don't know - SKIP to 25a

b. In a typical month, how many retirees under 65 years of age were enrolled in health insurance through your organization at all 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 2017, 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 2017, 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

AGE 65 OR OLDER