Form #1 Prescreener Questionnaire

Health Insurance Cost Study

MPS-24

MEDICAL EXPENDITURE PANEL SURVEY
INSURANCE COMPONENT
JOB AID 2
INSTRUMENT ITEMS BOOKLET
2022 SURVEY YEAR

Block A – Plan Availability
>INSAVAIL<
For this study, a health insurance plan is defined as a plan where hospital and/or physician
coverage is made available to employees.
In 2022, did your [organization/government unit] offer any health insurance plans to its ACTIVE
employees at your [fill address] location?
(You told me earlier that you do not offer insurance. We include any coverage provided through
a union, insurance carrier, professional association or coverage self-insured by your
[organization/government unit]. [We also include insurance provided to ACTIVE employees
through your state or another government unit.] In 2022, did you offer health insurance through
any of these methods?)
Press F10 if New Contact Needed.
(1) Yes
(2) No
(3) Volunteers State/other government unit administered insurance
>INSAVAIL_PROBE<
We include any coverage provided through a union, insurance carrier, professional association,
or coverage self-insured by your [organization/government unit]. (We also include insurance
provided to ACTIVE employees through your state or another government unit.) In 2022, did
you offer health insurance through any of these methods?
(1) Yes
(2) No
(3) Volunteers State/other government unit administered insurance
>REFCONVERT<
This very important study is of national concern since it will have an impact on each and every
one of our lives. It is very important that we have your cooperation to ensure the validity and
accuracy of the data. Please be assured that all of your responses will be kept strictly
confidential. May we please continue?
(1) Yes
(2) No

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Job Aid 2

ITEMS BOOKLET

1

>MAYWEMAIL<
May I have the name of the contact person and mailing address where we can send the
questionnaire?
(1) Yes
(2) No
>HOWMANYPLANS<
During the 2022 plan year, how many different health insurance plan choices did your
[organization/government unit] offer to its ACTIVE employees [at your (fill address) location]?
Read if necessary: We only count comprehensive plans which cover hospital and/or physician
coverage.
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.
Number of Plans:
>ZEROPLANPROBE<
The number of health plans should include any variety of options offered by a health insurance
carrier which cover hospital stays and/or physician care. These options may cover differing
levels of benefits.
Only comprehensive plans should be included.
Employers do not need to contribute to the plan premium in order for it to be counted.
Would you like to change your answer from the zero plans reported?
(1) Yes
(2) No

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Job Aid 2

ITEMS BOOKLET

2

>GOVADMIN< (Govs)
What is the name of the state or other government unit that administered the health insurance
plan(s)?
State/Other government unit name:
>STATEREPORT< (Govs)
Is there someone located at your government unit who would be able to provide information
about the health insurance plan(s) such as the type of provider arrangement, premiums,
deductibles, and enrollments?
(1) Yes
(2) No
>PRIORYEARINS<
In 2021, did your [organization/government unit] offer any health insurance plans to its ACTIVE
employees at the location I just mentioned?
(1) Yes
(2) No

>CHANGEACTEMPS<
In 2021, did your [organization/government unit] have a net change in the number of active
employees in response to the Coronavirus pandemic or related economic conditions?
(1) Yes, net increase
(2) Yes, net decrease
(3) No net change in number of active employees

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Job Aid 2

ITEMS BOOKLET

3

Block B – Insurance Available
>LOCATIONEMP<
For this study, we define an "employee" as any worker for whom your organization withheld
taxes including owners, part-time, and seasonal employees. We do not include former
employees, leased or contract workers, or retirees.
In 2022, approximately how many employees were on your organization's payroll at the location
I mentioned earlier for a typical pay period?
Note: Do not attempt a new contact if this is the only item the respondent cannot answer.
Number of Employees:
>EMPZERO<
Please keep in mind that the period of reference for this study is a typical pay period in 2022.
Include anyone for whom taxes were withheld. Include anyone for whom taxes were withheld.
Include the owner as an employee if the owner works the majority of the time at this location.
We also include all full- or part-time, temporary and seasonal employees as well as members of
any union who are employed by your organization.
Would you like to change your answer from the zero employees reported?
(1) Yes
(2) No
>GOVEMP<
In 2022, how many ACTIVE employees were on your government unit's payroll for a TYPICAL
pay period?
Number of Employees:

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Job Aid 2

ITEMS BOOKLET

4

>GOVEMPZERO<
Please keep in mind that the period of reference for this study is a typical pay period in
2022. Include anyone for whom taxes were withheld. We include all full- or part-time,
temporary and seasonal employees as well as members of any union who are employed by
your government unit.
Would you like to change your answer from the zero employees reported?
(1) Yes
(2) No

>PVTEXCHANGE<
Did your [organization/government unit] offer health insurance to active employees through a
private exchange, also known as a corporate exchange?
(1) Yes
(2) No
>ICHRAQSEHRA<
Did your organization offer an Individual Coverage Health Reimbursement Arrangement
(ICHRA) or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)? If
response is “yes” probe to see which one was offered:
Which one was offered, an ICHRA or QSEHRA?”
(1) Yes, offered ICHRA
(2) Yes, offered QSEHRA
(3) No, did not offer either arrangement

>TW_ABLE_YN<
Is this employee able to do their job by teleworking if necessary?
(1) Yes
(2) No

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Job Aid 2

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>TW_ABLE_NUM/PCT<
How many employees are able to do their jobs by teleworking if necessary?
Read if necessary: Can you provide a percentage value?
Number or Percent of Employees
>TW_EMPS_YN<
Is this employee able to telework on a regular basis?
(1) Yes
(2) No

>TW_EMPS_NUM/PCT<
How many employees telework on a regular basis?
Number or Percent of Employees

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Job Aid 2

ITEMS BOOKLET

6

>CP_NAME<, >CP_TITLE<, >CP_PHONE<, >CP_EXTN<
Read if necessary: The questionnaire contains items about the health insurance provider options,
premiums, and enrollment as well as some employee characteristics and fringe benefits.
We will be mailing a questionnaire for this study to obtain information about the health
insurance plans offered, such as health care provider options, premiums, and enrollment as well
as other characteristics of your [business/government unit] such as fringe benefits and employee
characteristics.
Read if necessary:
Are you the correct person to receive this questionnaire?
OR
May I have the name, title and phone number of the Benefits Manager or other person to whom
the questionnaire should be addressed?
Contact Person Name:
Contact Person Title:
Contact Person Phone:
Contact Person Extension:
>CPMAIL_MNAME1<, >CPMAIL_MNAME2<, >CPMAIL_MSTREET1<,
>CPMAIL_MSTREET2<, >CPMAIL_PLACE<, >CPMAIL_STATE<, >CPMAIL_ZIP5<,
>CPMAIL_ZIP4<
Read if necessary:
What is your mailing address, starting with your [organization’s/government unit’s] name?
Mail CoName1:
Mail CoName2:
Mail Street1:
Mail Street2:
Mail City:
Mail State:

Mail Zip:

>FC_COUNTRY<
Enter foreign country name.
Country:

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Job Aid 2

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>FC_POSTALCODE<
Enter the foreign postal code.
Postal Code:
>PLANNAMES<
We would like to send labeled questionnaires requesting detailed information on your
organization's health insurance plans.
Please provide me with the names of the [fill number of plans] health insurance plans your
organization made available to its active employees in 2022 in order of enrollment, naming the
plan with the largest enrollment of active employees first.
Number of plans reported: [fill number of plans]
Press F10 if New Contact Needed.
If there is a union plan, but the respondent is unable to provide the name of the plan, enter
“Union Plan” to hold the place for the union plan data collection.
Enter 999 if No More Plans can be named.
Health plan name:
>SPELLING_REVIEW<
Review the list of plan names. Do you need to make any changes?
(List of plan names)
(1) No Changes Needed
(2) Change the number of plans
(3) Add, Edit, Delete plan names

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Job Aid 2

ITEMS BOOKLET

8

>CHANGENUMBERPLANS<
Current number of plans: [fill number of plans]
We only count comprehensive plans which cover hospital and/or physician coverage.
Include union sponsored plans.
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.
Enter the New Number of Plans:
>INSERTDELETE<
To insert a row before the current row, Select ‘1’ in the first column. To delete the current row,
select ‘2’ in the first column.
To edit a plan name, use the arrow keys to move to the plan you would like to edit.
When you are finished making changes, enter through the last plan name field with ‘999’.
(List of plans)

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Job Aid 2

ITEMS BOOKLET

9

Block C – No Insurance
>NOINSAVAIL<
Read if necessary:
In order to make our study representative, we need to ask a few more questions of those
establishments which did not offer available in 2022.
These questions include: some general questions about the classification of employees, the types
of employees, and the fringe benefits offered.
>MORETHAN1LOCATION<
Ask or Verify: Does your organization have more than one location?
(1) Yes
(2) No
>TOTALEMPALL<
For this study, we define an "employee" as any worker for whom your organization withheld
taxes, including owners, part-time, and seasonal employees. We do not include former
employees, leased or contract workers, or retirees.
Approximately how many total employees did your organization have at ALL locations for a
TYPICAL pay period in 2022?
Number of Employees:
>LOCATIONEMP<
For this study, we define an "employee" as any worker for whom your organization withheld
taxes, including owners, part-time, and seasonal employees. We do not include former
employees, leased or contract workers, or retirees.
Approximately, how many employees were on your organization's payroll at the location I
mentioned earlier for a typical pay period in 2022?
Number of Employees:

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Job Aid 2

ITEMS BOOKLET

10

>EMPZERO<
Please keep in mind that the period of reference for this study is a typical pay period in 2022.
Include anyone for whom taxes were withheld. Include the owner as an employee if the owner
works the majority of the time at this location. We also include all full- or part-time, temporary
and seasonal employees as well as members of any union who are employed by your
organization.
Would you like to change your answer from the zero employees reported?
(1) Yes
(2) No
>EMPCLASS_INTRO<
The next set of questions will ask about different employee classifications. Estimates or
percentages are acceptable where numeric replies are needed.
>GOVEMP<
In 2022, how many ACTIVE employees were on your government unit's payroll for a TYPICAL
pay period?
Number of Employees:
>GOVEMPZERO<
Please keep in mind that the period of reference for this study is a typical pay period in 2022.
Include anyone for whom taxes were withheld. We include all full- or part-time, temporary and
seasonal employees as well as members of any union who are employed by your government
unit.
Would you like to change your answer from the zero employees reported?
(1) Yes
(2) No

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Job Aid 2

ITEMS BOOKLET

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>DEMOCHARS_PARTTIME_NUM<
How many [of the [fill number of employees]] employees at this location were part-time?
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:
>LESSHOURS_NUM/PCT<
How many [of the [fill number of employees]] employees at this [location/government unit]
worked fewer than 30 hours per week?
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:

>DEMOCHARS_UNION_NUM/PCT<
How many [of the [fill number of employees]] employees at this [location/government unit]
were union members?
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:

>DEMOCHARS_WOMEN_NUM/PCT<
How many [of the [fill number of employees]] employees at this [location/government unit]
were women?
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:

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Job Aid 2

ITEMS BOOKLET

12

>DEMOCHARS_50PLUS_NUM/PCT<
How many [of the [fill number of employees]] employees at this [location/government unit]
were 50 years old or older?
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:
>WAGES_UNDER_NUM<
How many [of the [fill number of employees]] employees at this [location/government unit]
made:
Less than $14.50 per hour?
Read if necessary: This is about $30,160 a year or less.
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:
>WAGES_BTWN_NUM<
How many [of the [fill number of employees]] employees at this [location/government unit]
made:
Between $14.50 and $34.00 per hour?
Read if necessary: This is between $30,160 and $70,720 a year.
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:
>WAGES_OVER_NUM<
How many [of the [fill number of employees]] employees at this [location/government unit]
made:
More than $34.00 per hour?
Read if necessary: This is about $70,720 or more per year.
Read if necessary: Can you provide a percentage value?
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Job Aid 2

ITEMS BOOKLET

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Number or Percentage of Employees:
>WAGES_HIGHEST_NUM<
How many [of the [fill number of employees]] employees at this [location/government unit]
made:
More than $53.50 per hour?
Read if necessary: This is about $111,280 or more per year.
Read if necessary: Can you provide a percentage value?
Number or Percentage of Employees:
>TW_ABLE_YN<
Is this employee able to do their job by teleworking if necessary?
(1) Yes
(2) No

>TW_ABLE_NUM/PCT<
How many employees are able to do their jobs by teleworking if necessary?
Read if necessary: Can you provide a percentage value?
Number or Percent of Employees
>TW_EMPS_YN<
Is this employee able to telework on a regular basis?
(1) Yes
(2) No

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Job Aid 2

ITEMS BOOKLET

14

>TW_EMPS_NUM/PCT<
How many employees telework on a regular basis?
Number or Percent of Employees

>FRINGEBENEFITS_VAC<, >FRINGEBENEFITS_SICK<, >FRINGEBENEFITS_LIFE<,
>FRINGEBENEFITS_DISABLE<, >FRINGEBENEFITS_CRITICAL< ,
>FRINGEBENEFITS_RETIRE<
I am going to read a list of 6 types of benefits. As I read each one, please indicate whether or not
your [organization/government unit] offered that benefit to its employees at this location.
Paid Vacation?
If Paid Time Off (PTO) is offered, enter 'Yes'.
Paid Sick Leave?
If Paid Time Off (PTO) is offered, enter 'Yes'.
Life Insurance?
Disability Insurance?
Critical Illness Insurance?
Retirement or Pension Plans?
(1) Yes
(2) No
>TAXADBENEFITS_FSA<, >TAXADBENEFITS_FBP<
Did your [organization/government unit] offer either of the following tax advantaged benefits to
its employees at this location?
Flexible Spending Accounts for healthcare?
Flexible Benefits Plans also known as Full Cafeteria Plans?
(1) Yes
(2) No

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Job Aid 2

ITEMS BOOKLET

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>ICHRAQSEHRA<
Did your organization offer an Individual Coverage Health Reimbursement Arrangement
(ICHRA) or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)? If
response is “yes” probe to see which one was offered:
Which one was offered, an ICHRA or QSEHRA?
(1) Yes, offered ICHRA
(2) Yes, offered QSEHRA
(3) No, did not offer either arrangement

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Job Aid 2

ITEMS BOOKLET

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