Various Governments Pretesting Activites

OMB No. 0935-0110: Approval Expires 12/31/2014

2012 Medical Expenditure Panel Survey
Insurance Component

HEALTH INSURANCE
COST STUDY
Government Questionnaire

(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

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
FORM MEPS-11C(F) (02-10-2012)

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29062015

INTERNET RESPONSE
You may respond to this survey via the Internet at the following web address:
https://respond.census.gov/meps11
Your Survey Key to access the Internet form is:

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INSTRUCTIONS
1. Please report for the government unit identified on the cover
sheet.
2. Report data for the year 2012.
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 copy of this completed form for your records.
7. In addition to the completed questionnaire, please include a copy
of each of your health insurance plan brochures describing
the benefits offered, or a copy of the benefits sheet summarizing the
benefits offered by each of your plans.

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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 U.S. 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, Room 5030, 540
Gaither Road, Rockville, MD 20850. 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.

FORM MEPS-11C(F) (02-10-2012)

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8. If you have any questions or need assistance in completing the
questionnaire, please call 1-888-206-5068.

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Section A – NUMBER OF PLANS
Please respond for the government unit identified on the cover sheet.
Respond for ACTIVE employees only.

1a. Did your government unit make available or

001

contribute to the cost of any health insurance
plans for its ACTIVE employees in 2012?

1

Yes – Continue with Question 1b

2

No – Complete contact information
below then SKIP to
MEPS-11C(R), Section C

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

b. How many different health insurance plan
choices did your government unit make
available or contribute to for its ACTIVE
employees during the 2012 plan year?

003

Number of health plans offered

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.

c. Are health benefits brochures for those plans

671

available on a website?
Please provide, in remarks section below, the general user
information to access brochures, if needed and available.

Yes – Please provide website address below

2

No – Complete contact information
below then CONTINUE with
MEPS-11C(S), Section B

Remarks

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CONTACT INFORMATION – PERSON COMPLETING THIS QUESTIONNAIRE
212 Name (Please print)

213 Title (Please print)

Signature

217 Email (Please print)

220 Extension 216 Fax

215 Telephone number

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–

670 Brochure Website address

214 Date (Month/Day/Year)

http: //
FORM MEPS-11C(F)
(02-10-2012)

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PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS