Form 1 Pilot test – Establishment Questionnaire

OMB No. 0935-0124: Approval Expires 01/31/2024

Medical Expenditure Panel Survey
Insurance Component

2021 HEALTH INSURANCE
COST STUDY

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

TO COMPLETE THIS SURVEY ONLINE
Visit: https://portal.census.gov

29011012

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
FORM

MEPS-10

(02-25-2021) Draft 4

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Authentication Code:

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INSTRUCTIONS
1. Please report for the location identified on the cover sheet, unless
otherwise specified.
2. Please report data for the year 2021.
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.

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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 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 0935-0124, 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.
FORM

MEPS-10

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7. For assistance completing this survey, please log-in to your
Census Bureau account at https://portal.census.gov and send
us a secure message OR call
at
, Monday through Friday, 8:30 a.m. to 5:00 p.m.
Eastern Time.

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NUMBER OF PLANS
Respond for ACTIVE employees only.

1

In 2021, did your organization offer any health
insurance plans to its ACTIVE employees at this
location?

001

1

Yes – Continue with 2

2

No – SKIP to

3

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

2

During the 2021 plan year, how many different
health insurance plan choices did your
organization offer to its ACTIVE employees at
this location?

003

Health insurance plan choices at this location

Do not count single service plans (optional plans) such as
dental or vision.
ჀSingle, employee-plus-one, and family coverage providing
the same level of benefits from the same insurance
company count as ONE plan.
ჀHigh and standard options count as TWO plans.
ჀAn HMO and a PPO from the same insurance company
count as TWO plans.

PRIOR YEAR OFFERING
In 2020, did your organization offer any health
insurance plans to its ACTIVE employees at
this location?

741

1

Yes – Offered

2

No – Not offered

3

Don’t know

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3

Continue with 4
FORM

MEPS-10

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EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility, and enrollment figures.
For Questions 4 through 11b, if the answer is NONE, please enter "0".
Include:
● Corporate officers and managers
● Employees on the payroll for this location, including:
those who work off-site.
those who are leased or contracted TO other organizations.
● Full-time and part-time employees
● Owners
● Temporary and seasonal employees

4

In 2021, what was the total number of
employees your organization had at ALL
locations for a typical pay period?

Exclude:
● Former employees
● Workers leased or contracted
FROM other organizations
● Retirees

034

,

Employees at all locations

,

All employees at this
location

Complete Questions 5a through 22 for the location listed on the cover sheet.

5

a. How many employees were on your

200

organization’s payroll AT THIS LOCATION
for a typical pay period?

If your organization did not offer
health insurance in 2021, SKIP to 6a .

b. How many of these employees were

201

ELIGIBLE for at least one health plan
through your organization?

c. How many of these employees were

a. For the same TYPICAL pay period, how many

Eligible employees

,

Enrolled employees

,

Part-time employees

202

ENROLLED in any health plan through
your organization?

6

,

203

of the employees reported in Question 5a
worked part-time?

If your organization did not offer
health insurance in 2021, SKIP to 7 .
204

were ELIGIBLE for at least one health plan
through your organization?

c. How many of these part-time employees

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

Is the information you provided in Questions 5
through 7 for the location listed on the cover
sheet OR did you provide information for
multiple locations?

,

Enrolled part-time employees

,

Employees worked fewer
than 30 hours

742

743

8

Eligible part-time employees

205

were ENROLLED in any health plan through
your organization?

7

,

550

No employees worked fewer than 30 hours.

1

Information for specified location

2

Information for multiple locations

If your organization did not offer
health insurance in 2021, SKIP to 10a .

Continue with 9
FORM

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b. How many of these part-time employees

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EMPLOYMENT CHARACTERISTICS - Continued
9

What was the minimum number of hours per
week that an employee had to work in order
to be eligible for health insurance?

626

721

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

Provide information for a TYPICAL pay period in 2021.
Estimates are acceptable.

10

a. Approximately what percentage of the

018

employees at this location were union
members?

%
729

b. Approximately what percentage of the

No union members

016

employees at this location were women?

c. Approximately what percentage of the

Union members

%

Women employees

%

Employees 50 years old or older

%

Earned less than $13.50 per hour

%

Earned between $13.50 and $32.00
per hour

%

Earned more than $32.00 per hour

017

employees at this location were 50 years
old or older?

d. For the employees at this location,

approximately what percentage earned:
022

Less than $13.50 per hour?
Approximately $28,080 a year or less . . . . . . . . . . . . . . . . . .

023

Between $13.50 and $32.00 per hour?
Approximately $28,080 to $66,560 a year . . . . . . . . . . . . . . .

024

More than $32.00 per hour?
Approximately $66,560 a year or more . . . . . . . . . . . . . . . . .

1 0 0 %

e. For the employees at this location,

726

approximately how many earned more
than $50.50 per hour?

Number of employees that earned
more than $50.50 per hour



Approximately $105,040 a year or more

a. For the employees at this location, what

796

percentage telework on a regular basis?

%

Teleworking employees

%

Employees able to do
their jobs by teleworking

For example, once a week, once a pay period,
monthly, etc.
Estimates are acceptable. Include all position types.
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b. For the employees at this location, what
percentage are able to do their jobs by
teleworking if necessary?

797

Necessary - Due to pandemic, inclement weather or
other circumstances that make it difficult or inadvisable
to work in the office.
Estimates are acceptable. Include all position types.

Continue with 12
FORM

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11

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EMPLOYMENT CHARACTERISTICS - Continued
12

In 2021, did your organization have a net
change in the number of active employees in
response to the Coronavirus pandemic or
related economic conditions at this location?

798

1

Yes, net increase

2

Yes, net decrease

3

No net change in number of active employees

4

Don’t know

FRINGE BENEFITS CHARACTERISTICS
13

Did your organization offer the following fringe
benefits to its employees at this location?
If Paid Time Off (PTO) is offered, mark (X) Yes for paid
vacation AND paid sick leave.

Critical illness insurance is a special form of insurance that
pays the policyholder a lump-sum, tax-free payment if they
suffer from serious illnesses, including but not limited to
cancer, heart attack, kidney failure and stroke.

Yes
(1)
050

Paid vacation . . . . . . . . . . . . . . . . . .

051

Paid sick leave . . . . . . . . . . . . . . . . .

052

Life insurance . . . . . . . . . . . . . . . . .

053

Disability insurance . . . . . . . . . . . . .

795

Critical illness insurance . . . . . . . . . .

054

Retirement/pension plans . . . . . . . . .

Don’t
No know
(2)

(3)

TAX-ADVANTAGED BENEFITS
Did your organization offer any of these
tax-advantaged benefits to its employees at
this location?
See the definition sheet MEPS-20(D) included with this
package for an explanation of these benefits.

Yes
(1)
627

Employee contributions to health
insurance made on a pre-tax basis . .

056

Flexible Spending Accounts
(FSA) for healthcare . . . . . . . . . . . . .

057

Flexible Benefits Plans . . . . . . . . . . .
Full cafeteria plans that offer
employees a set of benefits
from which to choose.

Don’t
No know
(2)

(3)

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14

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If your organization offered health insurance, continue with 15 .
If your organization DID NOT offer health insurance, SKIP to 22 .

Continue with 15
FORM

MEPS-10

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HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS
15

Did your organization offer health insurance to
active employees through a private exchange
(also known as a corporate exchange)?

765

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

16

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

If your organization has more than 100 employees at all
locations, SKIP to 17a . Otherwise, continue with 16 .

770
1

Yes

2

No

3

Don’t know

GENERAL HEALTH COVERAGE CHARACTERISTICS
17

a. Did your organization offer any of the listed

optional coverage services at a premium
SEPARATE from the comprehensive health plan
to the active employees at this location?
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.

Yes
(1)
192

Dental . . . . . . . . . . . . . . . . . . . . . . .

193

Vision . . . . . . . . . . . . . . . . . . . . . . .

194

Prescription drugs . . . . . . . . . . . . . .

195

Long-term care . . . . . . . . . . . . . . . .

coverage for all active employees during a
TYPICAL MONTH at this location?

$





.00

Monthly total optional coverage cost
197



Yes



No



Don’t know

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Did your organization impose a waiting
period before new employees could be covered
by health insurance?

(3)

720

Include both employer and employee contributions.

18

(2)

No optional coverage – SKIP to 18

562

b. What was the total amount paid for optional

Don’t
No know

Continue with 19
FORM

MEPS-10

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GENERAL HEALTH COVERAGE CHARACTERISTICS - Continued
19

20

21

22

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

Were employees’ SPOUSES eligible for health
insurance coverage through your organization?

723

745



Yes



No



Don’t know



All spouses eligible, HIGHER employee
contribution paid if spouse eligible through
own employer.



All spouses eligible, SAME employee
contribution.



All spouses eligible, don’t know employee
contribution.



Limited spouses eligible, only if not offered
by own employer.



No spouses eligible.



Don’t know

Did your organization offer health insurance
coverage to UNMARRIED domestic partners?

Did your organization offer an Individual
Coverage Health Reimbursement Arrangement
(ICHRA) or Qualified Small Employer Health
Reimbursement Arrangement (QSEHRA)?
ICHRA/QSEHRA are not traditional HRAs. If only a traditional
HRA was offered, select ’No’.

(1)
730

Same sex domestic partners . . . . . . .

731

Opposite sex domestic partners . . . .

794



Yes, offered ICHRA



Yes, offered QSEHRA



No, did not offer either arrangement



Don’t know

Don’t
No know
(2)

(3)

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

Yes

Continue with 23
FORM

MEPS-10

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RETIREE HEALTH COVERAGE CHARACTERISTICS
Please complete Questions 23 through 25g for ALL LOCATIONS. If the answer is NONE, please enter "0".
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 2021 OR BEFORE, or to any
of their survivors?

551

If COBRA was the only coverage offered, mark "No."

24

In a typical month, how many retirees
were enrolled in health insurance through
your organization at all locations?
If this was a self-insured plan, report the premium
equivalent.

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

d. For a typical plan, how much did the

EMPLOYER contribute, by age category,
toward the monthly plan premium for one
typical retiree with SINGLE coverage?

e. For this same plan, what was the

TOTAL monthly premium, by age
category, for this typical retiree with
SINGLE coverage?

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f.

For a typical plan, how much did the
EMPLOYER contribute, by age category,
toward the monthly plan premium for
one typical retiree with FAMILY
coverage?

No



Don’t know

}

SKIP to the bottom of page 10
to complete form.

Number of retirees enrolled

UNDER 65 YEARS OF AGE

reported in Question 24, under 65
years of age or age 65 or older?

number of retirees, by age category,
enrolled in health insurance through
your organization at all locations?





a. Were any of the enrolled retirees,

b. In a typical month, what was the TOTAL

Yes – Continue with 24

513

628

25



1

Yes

2

No

3

Don’t
know

572

629

}

SKIP to
Age 65
or Older

Total
under
65



573

%

AGE 65 OR OLDER

Percent of
under 65
enrolled
in single

1

Yes

2

No

3

Don’t
know

578

}

SKIP to
26a

Total
65 or
older



579

%

Percent of
65 or older
enrolled
in single

580

574

$



.00

$



.00

$



.00

$



.00

$



.00

581

575

$



.00
582

576

$



.00

If premium varied by family size, report for a
family of two.

g. For this same plan, what was the

TOTAL monthly premium, by age
category, for this typical retiree with
FAMILY coverage?

577

583

$



.00

Continue with 26a
FORM

MEPS-10

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23

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RETIREE HEALTH COVERAGE CHARACTERISTICS

Continued

NEW RETIREES
For Questions 26a through 26c, NEW RETIREES refers only to persons who retired from your organization in 2021.
Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws.
630

26

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

b. Were NEW RETIREES under 65 years of age

631

eligible for health insurance?

c. Were NEW RETIREES age 65 or older eligible

632

for health insurance?

500



Yes – Continue with 26b



No



Don’t know



Yes



No



Don’t know



Yes



No



Don’t know

}

SKIP to the bottom of this
page to complete form.

Remarks

PERSON COMPLETING THIS QUESTIONNAIRE
Name (Please print)

Title (Please print)

212

213

Area code

Number

220

215

Extension

MM

DD

YYYY

214

–

–

Email
29011103

217

*** PLEASE NOTE ***
If your organization offered health insurance, please complete the attached
MEPS-10(S), Plan Information Questionnaire, for each plan offered (up to four plans).
If your organization DID NOT offer health insurance, you have completed the survey.

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM

MEPS-10

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–