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pdfOMB No. 0935-0110: Approval Expires 12/31/2014
Section B – GENERAL PLAN INFORMATION
FOR CENSUS USE ONLY
Answer Questions 1-16 for each plan
offered. Begin with the plan having the largest enrollment and proceed through to the
plan with the smallest enrollment of ACTIVE
employees. Report for a typical pay
period in 2012.
FOR CENSUS USE ONLY
100
100
012 Name of plan
012 Name of plan
Total ACTIVE employees ENROLLED
in plan
125
125
ACTIVE employees ENROLLED in
SINGLE coverage
129
2012 ENROLLMENTS
1a.
b.
Total
Total
129
Single
Single
c.
ACTIVE employees ENROLLED in
EMPLOYEE-PLUS-ONE coverage
571
571
Employee + 1
Employee + 1
Include both employee + spouse and
employee + child(ren).
See definition sheet for more information.
d.
ACTIVE employees ENROLLED in
FAMILY coverage
705
705
Family
Family
2.
FORMER employees ENROLLED
through PHSA (COBRA) or state
continuation-of-benefits laws, excluding
retirees
126
126
Former
PHSA (COBRA)
Former
PHSA (COBRA)
2012 PREMIUMS
b.
c.
Single Coverage
552
Not offered - Skip to Question 4a
2
Government/Employer contribution for
single premium
131
Employee contribution for single premium
132
29072014
4a.
,
b.
c.
d.
570
,
Employee contribution for
employee-plus-one premium
637
Total employee-plus-one
premium
FORM MEPS-11C(S) (03-02-2012)
$
.00
,
$
.00
Not offered - Skip to Question 5a
2
636
,
.00
,
.00
130
$
Government/Employer contribution for
employee-plus-one premium
$
.00
132
$
Total single premium
Employee-plus-one Coverage
Not offered - Skip to Question 4a
2
131
$
130
d.
552
570
,
.00
Not offered - Skip to Question 5a
2
636
$
,
$
.00
,
.00
637
$
,
$
.00
635
,
.00
635
$
,
.00
$
,
.00
§>(5/¤
3a.
2
Section B – GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
2012 PREMIUMS - Continued
5a. Family Coverage
b. Government/Employer contribution for
137
135
,
.00
,
$
.00
,
134
.00
,
134
$
133
Mark (X) ONLY one.
$
136
$
d. Total family premium
The amounts reported in the
premium questions are based
on which of the following time
periods?
Not offered - Skip to Question 6
2
.00
136
premium
6.
137
135
$
family premium
c. Employee contribution for family
Not offered - Skip to Question 6
2
$
.00
,
1
Weekly
5
Quarterly
2
Every 2
weeks
4
Yearly
3
Monthly
1
Coverage was underwritten
by an insurer - Skip to
Question 9
2
133
.00
,
1
Weekly
5
Quarterly
2
Every 2
weeks
4
Yearly
3
Monthly
1
Coverage was underwritten
by an insurer - Skip to
Question 9
Plan was self-insured Continue with Question 8a
2
Plan was self-insured Continue with Question 8a
3
Don’t know - Skip to
Question 9
3
Don’t know - Skip to
Question 9
1
Yes - Used TPA or ASO
1
Yes - Used TPA or ASO
2
No - Self-administered the plan
2
No - Self-administered the plan
1
Yes
1
Yes
2
No
2
No
1
Union
1
Union
2
Trade Association
2
Trade Association
3
Neither
3
Neither
7.
Was this plan purchased from
an insurance underwriter or
was it self-insured?
105
Coverage was underwritten by
an insurer and the insurer paid the
enrollee’s claim.
The plan was self-insured if
government paid enrollee’s claim
directly or through a third party
administrator (TPA).
29072022
8a.
Complete Questions 8a-b if this plan
was self-insured.
Did your government unit
employ a third party
administrator (TPA) or purchase
administrative services only
(ASO) from an insurer for this
self-insured plan?
b. Did your government unit
713
107
purchase stop-loss coverage for
this plan?
105
713
107
PLAN AFFILIATION
9.
Was this plan offered through a
union or a trade association?
A trade association is a group of
individuals or companies in a
specific business or industry
organized to promote a common
interest.
FORM MEPS-11C(S) (03-02-2012)
113
113
§>(57¤
SELF-INSURED PLAN INFORMATION
3
Section B – GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
PLAN INFORMATION
10. In what month did the plan
Enter a two-digit numeric response.
year begin?
Enter a two-digit numeric response.
Example: January=01; May=05
123
Example: January=01; May=05
123
Month
11. Could this plan have refused to
183
cover persons with pre-existing
medical or health conditions?
12. Did this plan have a policy
13. Did the PREMIUMS CHARGED by
the insurance company or carrier
vary by any of these employee
characteristics?
If self-insured, mark (X) premiums did
not vary.
1
Yes
2
No
1
Yes
2
No
185
requiring a waiting period
before covering pre-existing
conditions?
Month
183
1
Yes
2
No
1
Yes
2
No
185
138
Age
138
Age
139
Gender
139
Gender
141
Wage or salary level
141
Wage or salary level
142
Other
142
Other
Mark (X) all that apply.
OR
14. Did the amount an EMPLOYEE
CONTRIBUTED toward his/her
own coverage vary by any of
these employee characteristics?
OR
640
Premiums did not vary
640
Premiums did not vary
641
Hours worked
641
Hours worked
642
Union status
642
Union status
643
Wage or salary level
643
Wage or salary level
644
Occupation
644
Occupation
706
Length of Employment
706
Length of Employment
645
Other
645
Other
OR
OR
646
FORM MEPS-11C(S) (03-02-2012)
Employee contribution did
not vary
646
Employee contribution did
not vary
§>(5?¤
29072030
Mark (X) all that apply.
4
GENERAL PLAN INFORMATION – Continued
FOR CENSUS USE ONLY
100
FOR CENSUS USE ONLY
100
Name of plan
Name of plan
HEALTH SAVINGS ACCOUNT (HSA)
15. If the deductibles for this plan
714
were $1,200 or higher for single
coverage and $2,400 or higher
for family coverage, did your
government unit contribute to a
Health Savings Account (HSA)
for the plan enrollees in 2012?
1
Yes, contributed to an HSA
2
4
714
1
Yes, contributed to an HSA
No, did not contribute to an
HSA
2
No, did not contribute to an
HSA
Don’t know
4
Don’t know
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
16. 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. Did your
government unit offer an HRA
associated with this plan in
2012?
710
710
1
Yes
No
2
No
Don’t know
3
Don’t know
1
Yes
2
3
HRAs are NOT Flexible Spending
Accounts (FSAs) or Health Savings
Accounts (HSAs).
See definition sheet for more
information.
*** PLEASE NOTE ***
Complete a MEPS-11C(S) column for each plan that was offered.
REMEMBER TO ENCLOSE A COPY OF EACH PLAN BROCHURE OR PROVIDE THE BROCHURE
WEBSITE ADDRESS WITH YOUR CONTACT INFORMATION ON THE MEPS-11C(F). PLEASE PROVIDE
THE GENERAL USER INFORMATION IN THE REMARKS SECTION.
If you have any questions concerning this survey, please call 1-888-206-5068.
FORM MEPS-11C(S) (03-02-2012)
§>(5Q¤
29072048
If you have completed your last health insurance plan, continue
with form MEPS-11C(R), Section C.
File Type | application/pdf |
File Title | meps11csp1_12.g |
File Modified | 2012-05-01 |
File Created | 2012-03-22 |