2018 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY
Government Questionnaire

OMB No. 0935-0110: Approval Expires 11/30/2020
Form MEPS-11 (02-21-2018) Draft 3

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 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

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

  2. Please report data for the year 2018.

  3. Estimates are acceptable.

  4. For an explanation of unfamiliar terms, refer to the MEPS-20(D) Health Insurance Cost Study 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 estimate this survey will take 45 minutes, on average, to complete, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you offered more than two plans, we estimate an extra 11 minutes per additional plan. 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.

  1. Did your government unit make available or contribute to the cost of any health insurance plans for its ACTIVE employees in 2018?

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

    Yes - Continue with 2
    No - SKIP to 3



  2. How many different health insurance plan choices did your government unit make available or contribute to for its ACTIVE employees during the 2018 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 PPO from the same insurance company count as TWO plans.

    Health insurance plan choices at this location


PRIOR YEAR OFFERING

  1. In 2017, did your government unit make available or contribute to the cost of any health insurance plans for ACTIVE employees?

    Yes - Offered
    No - Not offered
    Don't know


EMPLOYMENT CHARACTERISTICS

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

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

Exclude former employees, leased or contract workers and retirees.

  1. a. How many employees were on your government unit’s payroll for a TYPICAL pay period in 2018?

    All employees

    No employees at this location – SKIP to Person Completing This Questionnaire

    If your government unit did not offer health insurance in 2018, SKIP to 5a.

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

    Eligible employees

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

    Enrolled employees



  2. a. For the same TYPICAL pay period in 2018, how many of the employees reported in Question 4a worked part-time?

    If none, enter "0".

    Part-time employees

    If your government unit did not offer health insurance in 2018, SKIP to 6.

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

    Eligible part-time employees

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

    Enrolled part-time employees


  3. How many of the employees reported in Question 4a worked fewer than 30 hours per week?

    Employees worked fewer than 30 hours
    No employees worked fewer than 30 hours

    If your government unit did not offer health insurance in 2018, SKIP to 8a.

  4. 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 2018.

Estimates are acceptable.

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

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

    % Union members
    No union members

    b. Approximately what percentage of the employees at this government unit were women?

    If none, enter "0".

    % Women employees

    c. Approximately what percentage of the employees at this government unit were 50 years old or older?

    If none, enter "0".

    % Employees 50 years old or older

    d. For the employees at this government unit in 2018, 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 $30.00 per hour?
    Approximately $25,000 to $62,000 a year
    % Earned between $12.00 and $30.00 per hour

    More than $30.00 per hour?
    Approximately $62,000 a year or more
    % Earned more than $30.00 per hour

    100%

    e. For the employees at this government unit in 2018, how many earned more than $47.00 per hour?

    Approximately $98,000 a year or more

    If none, enter "0".

    Number of employees that earned more than $47.00 per hour


FRINGE BENEFITS CHARACTERISTICS

  1. Did your government unit offer the following fringe benefits to its employees in 2018?

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

    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 government unit offer any of these tax-advantaged benefits to its employees in 2018?

    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     No     Don't know

    Flexible Spending Accounts (FSA) for healthcare
    Yes     No     Don't know

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

If your government unit DID make available or contribute to the cost of any health insurance coverage for its employees in 2018, continue with 11.

If your government unit DID NOT make available or contribute to the cost of any health insurance coverage for its employees in 2018, SKIP to 18.


HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS

  1. Did your government unit offer health insurance to 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.

    Yes
    No
    Don't know

If your government unit has more than 100 employees OR has more than 100 full-time equivalent employees (see definition sheet, MEPS-20(D)) at all locations, SKIP to 14a. Otherwise, continue with 12.


SMALL GOVERNMENT, 100 or FEWER EMPLOYEES

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

    Yes
    No
    Don't know



  2. Did your government unit use a third party, such as an insurance broker or agent, to help purchase the insurance plan(s)?

    Yes
    No
    Don't know


GENERAL HEALTH COVERAGE CHARACTERISTICS

  1. a. Which of the listed optional coverage services, if any, did your government unit offer to its ACTIVE employees in 2018 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 14b
    Vision - Continue with 14b
    Prescription drugs - Continue with 14b
    Long-term care - Continue with 14b
    No optional coverage - SKIP to 15

    b. What was the total amount paid for optional coverage for all ACTIVE employees during a TYPICAL MONTH in 2018?

    Include both government unit and employee contributions.

    $.00 Monthly total optional coverage cost



  2. For 2018, did your government unit impose a waiting period before new employees could be covered by health insurance?

    Yes
    No
    Don't know



  3. Were employees' SPOUSES eligible for health insurance coverage through your government unit?

    All spouses eligible, greater EMPLOYEE CONTRIBUTION paid if spouses eligible through own employer.
    All spouses eligible, same employee contribution.
    All spouses eligible, dont know employee contribution.
    Limited spouses eligible, only if not offered by own employer.
    No spouses eligible.
    Don't know


  4. Did your government unit offer health insurance coverage to UNMARRIED domestic partners?

    Same sex domestic partners ......... Yes    No    Don't know
    Opposite sex domestic partners ..... Yes    No    Don't know

RETIREE HEALTH COVERAGE CHARACTERISTICS

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.

  1. Did your government unit or some other government unit provide health insurance coverage to any person who retired in 2018 OR BEFORE, or to any of their survivors?

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

    Yes - This government unit - Continue with 19
    Yes - Another government unit -
    Name of other government unit
    Continue with 19 if information is available.
    Otherwise SKIP to Person Completing This Questionnaire
    No - SKIP to Person Completing This Questionnaire
    Don't know - SKIP to Person Completing This Questionnaire



  2. In a typical month, how many retirees were enrolled in health insurance through your government unit?

    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 19, under 65 years of age or age 65 or older?

    Yes
    No - SKIP to 21a, AGE 65 OR OLDER Section
    Don't know - SKIP to 21a, AGE 65 OR OLDER Section

    b. In a typical month, what was the TOTAL number of retirees, by age category, enrolled in health insurance through your government unit in 2018?

    Total under 65

    c. What percentage of these retirees, by age category, were ENROLLED in SINGLE coverage?

    % Percent of under 65 enrolled in single

    d. For a typical plan in 2018, how much did the GOVERNMENT UNIT contribute, by age category, toward the monthly plan premium for one typical retiree with SINGLE coverage?

    $.00

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

    $.00

    f. For a typical plan in 2018, how much did the GOVERNMENT UNIT contribute, by age category, 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

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

    $.00

AGE 65 OR OLDER

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 19, under 65 years of age or age 65 or older?

    Yes
    No - SKIP to 22a, NEW RETIREES Section
    Don't know - SKIP to 22a, NEW RETIREES Section

    b. In a typical month, what was the TOTAL number of retirees, by age category, enrolled in health insurance through your government unit in 2018?

    Total 65 or over

    c. What percentage of these retirees, by age category, were ENROLLED in SINGLE coverage?

    % Percent of 65 or older enrolled in single

    d. For a typical plan in 2018, how much did the GOVERNMENT UNIT contribute, by age category, toward the monthly plan premium for one typical retiree with SINGLE coverage?

    $.00

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

    $.00

    f. For a typical plan in 2018, how much did the GOVERNMENT UNIT contribute, by age category, 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

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

    $.00

NEW RETIREES

For Questions 22a through 22c, NEW RETIREES refers only to persons who retired from your government unit in 2018.

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

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

    Yes - Continue with 22b
    No - SKIP to Person Completing This Questionnaire
    Don't know - SKIP to Person Completing This Questionnaire

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

    Yes
    No
    Don't know

    c. Were NEW RETIREES age 65 or older eligible for health insurance?

    Yes
    No
    Don't know


Remarks

 

 


PERSON COMPLETING THIS QUESTIONNAIRE

Name (Please print)

Title (Please print)

Phone (Area code/Number/Extension)  - -

Date (MM/DD/YYYY)  - -

Email

*** PLEASE NOTE ***

If your government unit offered health insurance, please complete the attached MEPS-11(S), Plan Information Questionnaire, for all plans offered. If your government unit DID NOT offer health insurance, you have completed the survey.


PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS