Download:
pdf |
pdfOMB No. 0935-0110: Approval Expires 01/31/2026
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
2025 Medical Expenditure Panel Survey
Insurance Component
HEALTH INSURANCE COST STUDY
PLAN INFORMATION QUESTIONNAIRE
INSTRUCTIONS
REPORT FOR UP TO FOUR HEALTH INSURANCE PLANS OFFERED IN 2025 AT THE
LOCATION LISTED ABOVE.
Please use photocopies of this MEPS-10(S) form if sufficient copies were not included in this reporting
package.
GENERAL PLAN INFORMATION
If a plan name is preprinted in the Question 1 answer box below, answer for the plan specified. Otherwise, complete
this Plan Information Questionnaire for the plan with the largest (or next largest) enrollment of active employees.
1
For 2025, what was the name of the health
insurance plan with the largest (or next
largest) enrollment of ACTIVE employees?
012
Name of plan
Examples: Ⴠ Blue Cross Blue Shield, High Option
Ⴠ Option A
Ⴠ Aetna HMO
Which type of health care provider arrangement
was available through this plan?
Exclusive providers - Enrollees must go to "in-network"
providers associated with the plan for all non-emergency
care in order for the costs to be covered.
29025012
3
103
1
Exclusive providers
Any providers - Enrollees may go to providers of their
choice with no cost incentives to use a particular group of
providers. This is also known as an indemnity plan.
2
Any providers
Mixture of preferred and any providers - Enrollees
may go to any provider, but there is a cost incentive to use
a particular group of providers.
3
Mixture of preferred providers and any providers
1
Yes
2
No
3
Don’t know
1
Union (multi-employer health plan)
2
Trade or business association (AHP)
3
Neither
Did this plan REQUIRE that the enrollee see a
gatekeeper or primary-care physician in order
to be referred to a specialist?
104
For plans with multiple options, answer for the "in-network"
option.
4
Was this plan offered through a union
(multi-employer health plan) or a trade or business
association (Association Health Plan (AHP))?
Multi-employer Health Plan – An employee health benefit
plan maintained pursuant to a collective bargaining agreement
that includes employees of two or more employers.
Association Health Plan (AHP) – A group health plan
that employer groups and associations offer to provide health
coverage for their employees or members.
FORM
MEPS-10(S)
(02-24-2025)
113
Continue with 5
§>#S-¤
2
2
GENERAL PLAN INFORMATION - Continued
5
Was this plan purchased from an insurance
underwriter or was it self-insured?
105
Purchased from an insurance underwriter (Fully-insured) Coverage is purchased from an insurance
company or other underwriter who assumes the risk for
the enrollees’ medical expenses.
1
Purchased - SKIP to 7
2
Self-insured - Continue with 6a
3
Don’t know - SKIP to 7
Self-insured - Your organization assumes the risk for the
enrollees’ medical expenses and may charge a premium to
employees. This plan may be administered by a third party
and may employ supplemental stop-loss insurance to limit
unanticipated losses.
SELF-INSURED PLAN INFORMATION
6
a. Did your organization employ a third party
713
1
Yes - Used a TPA or ASO
2
No - Self-administered the plan
3
Don’t know
coverage for this plan?
1
Yes - Continue with 6c
See definition sheet MEPS-20(D) for more information.
2
No
3
Don’t know
administrator (TPA) or purchase
administrative services only (ASO) from an
insurer for this self-insured plan?
b. Did your organization purchase stop-loss
c. What was the stop-loss amount PER
107
}
SKIP to 7
732
$
ENROLLEE?
.00
818
Don’t know
7
Was this plan a level-funded plan?
1
Yes
2
No
3
Don’t know
29025020
Level-funded plan – In a level-funded plan, your
organization makes a set payment each month to an
insurer or third-party administrator which funds a reserve
account for claims, administrative costs, and premiums
for stop-loss coverage. When claims are lower than
expected, surplus payments may be refunded at the end
of the contract. These arrangements may also be
referred to as balanced funding or alternative
funding.
819
§>#S5¤
LEVEL‐FUNDED PLANS
Continue with 8
FORM
MEPS-10(S)
3
ACTUARIAL VALUE OR METAL LEVEL
8
What was this plan’s actuarial value AND/OR
metal level?
Actuarial Value:
747
%
Actuarial Value is the average percentage of total
enrollee medical expenses for plan covered benefits
paid by the plan, rather than by enrollee cost
sharing, for a typical group of enrollees.
of medical expenses paid by plan
AND/OR
Metal Level:
Metal Levels are labels for insurance plans that
describe the level of benefits and cost-sharing
provisions.
746
1
Bronze
2
Silver
3
Gold
4
Platinum
OR
Don’t know actuarial
value or metal level
776
9
Was this a grandfathered health plan as
defined by the Affordable Care Act?
739
See the definition sheet MEPS-20(D) included with
this package for an explanation.
1
Yes
2
No
3
Don’t know
ACTIVE ENROLLMENT
Estimates are acceptable for all enrollment figures.
For Questions 10a through 10d, if the answer is NONE, please enter "0".
Include:
Ⴠ Corporate officers and managers
Ⴠ Employees on the payroll for this location, including:
- those who work off-site
- those who are leased or contracted TO other organizations
Ⴠ Full-time and part-time employees
Ⴠ Owners
Ⴠ Temporary and seasonal employees
125
in this plan at this location during a typical
pay period?
b. How many of these active employees
29025038
Active employees enrolled in plan
Active employees enrolled in
single coverage
Active employees enrolled in
employee-plus-one coverage
Active employees enrolled in
family coverage
129
were enrolled in SINGLE coverage during
a typical pay period?
c. If this plan had EMPLOYEE-PLUS-ONE
coverage, how many active employees were
enrolled during a typical pay period?
571
Include enrollment for both employee-plus-spouse and
employee-plus-child coverage.
d. How many active employees were enrolled in
FAMILY coverage during a typical pay period?
705
Continue with 11
FORM
MEPS-10(S)
§>#SG¤
10 a. How many active employees were enrolled
Exclude:
Ⴠ Former employees
Ⴠ Workers leased or contracted
FROM other organizations
Ⴠ Retirees
4
COBRA ENROLLMENT
11 How many FORMER employees were enrolled
126
in this plan through COBRA or state
continuation-of-benefits laws during a typical
pay period? Exclude retirees.
Former employees enrolled in
plan, excluding retirees
PLAN PREMIUMS
Report for TYPICAL situations and enrollees. If premiums varied, report for a TYPICAL employee.
If this was a self-insured plan, report the premium equivalent.
Report employer/employee contributions and total premium for the same period during 2025.
12
The following questions, 13a through 15e,
refer to plan premium amounts. For which
time period will you be reporting
employer/employee contributions and total
premiums?
790
Mark (X) only one.
1
Weekly
2
Every 2 weeks
3
Monthly
5
Quarterly
4
Yearly
SINGLE COVERAGE
13 a. Was SINGLE coverage offered under this
552
plan?
b. For this plan, how much did the EMPLOYER
1
Yes - Continue with 13b
2
No - SKIP to 14a
131
contribute toward the plan premium of one
typical employee with single coverage?
c. How much did this typical EMPLOYEE with
.00
Employer contribution for
single premium
$
.00
Employee contribution for
single premium
$
.00
Total single premium
132
single coverage contribute toward their
own premium?
d. What was the TOTAL premium for this
$
130
typical employee with single coverage?
EMPLOYEE-PLUS-ONE COVERAGE
14
a. Was EMPLOYEE-PLUS-ONE coverage offered
570
29025046
under this plan?
b. For this plan, how much did the EMPLOYER
employee with employee-plus-one coverage?
2
No - SKIP to 15a
$
.00
Employer contribution for
employee-plus-one premium
$
.00
Employee contribution for
employee-plus-one premium
$
.00
Total employee-plus-one
premium
637
employee-plus-one coverage contribute
toward their own premium?
d. What was the TOTAL premium for this typical
Yes - Continue with 14b
636
contribute toward the plan premium of one
typical employee with employee-plus-one
coverage?
c. How much did this typical EMPLOYEE with
1
635
Continue with 15a
FORM
MEPS-10(S)
§>#SO¤
If employee-plus-one premiums were different for employee-plus-child and employee-plus-spouse coverage, report for
employee-plus-one child. If premiums varied for other reasons, report for a TYPICAL employee.
5
PLAN PREMIUMS - Continued
FAMILY COVERAGE
If premium varied by family size, report for a family of four.
15
a. Was FAMILY coverage offered under this
137
plan?
b. For this plan, how much did the EMPLOYER
1
Yes - Continue with 15b
2
No - SKIP to 16a
135
contribute toward the plan premium of one
typical employee with family coverage?
c. How much did this typical EMPLOYEE with
.00
Employer contribution for
family premium
$
.00
Employee contribution for
family premium
$
.00
Total family premium
134
employee with family coverage?
e. Did the TOTAL premium for family coverage
136
family coverage contribute toward their
own premium?
d. What was the TOTAL premium for this typical
$
752
vary depending on the number of family
members covered by the plan?
1
Yes
2
No
3
Don’t know
GENERAL PREMIUM INFORMATION
a. Did the amount individual EMPLOYEES
contributed toward their single coverage
premium vary by any of these
characteristics?
Do not include incentive programs that do not impact
contributions.
b. Was the TOTAL PREMIUM for an employee
Participation in a fitness/weight
loss program . . . . . . . . . . . . . . . . . . .
735
Participation in a smoking
cessation program . . . . . . . . . . . . . . .
761
Wellness/Health monitoring . . . . . . . . .
784
Age . . . . . . . . . . . . . . . . . . . . . . . . . .
785
Wage or Salary levels . . . . . . . . . . . . .
749
1
Yes
2
No
3
Don’t know
No
(2)
Don’t
know
(3)
29025053
with single coverage higher for older
workers?
734
Yes
(1)
§>#SV¤
16
Continue with 17
FORM
MEPS-10(S)
6
IN-NETWORK DEDUCTIBLES
17
18
Did this plan have a deductible?
What were the annual deductibles in this
plan for different levels of coverage?
Report "in-network" deductibles (if applicable).
151
1
Yes - Continue with 18
2
No - SKIP to 22
146
If deductible was per overnight hospital stay, it is not
an annual deductible and should be reported under
Question 24b on Page 8.
791
If prescription drugs had a separate deductible, it
should be reported under Question 26c on Page 8.
149
a. Did this plan require that a specific number
.00
Individual annual deductible
$
.00
Employee-plus-one
annual deductible
Employee-plus-one coverage not offered.
$
.00
Family annual deductible
Family coverage not offered - SKIP to 20
224
of family members meet their individual
deductibles before the family deductible
was met?
b. How many family members were required to
786
792
19
$
1
Yes - Continue with 19b
2
No - SKIP to 20
150
meet their individual deductibles before the
family deductible was met?
Number of family members
Report for a family of four.
HEALTH SAVINGS ACCOUNT (HSA)
Complete only if the deductibles for this plan were $1,650 or higher for single coverage and/or $3,300 or higher for
employee‐plus‐one or family coverage, otherwise skip to Question 22.
Did your organization contribute to a Health
Savings Account (HSA) for the plan enrollees?
714
1
Yes, contributed to an HSA
2
No, did not contribute
to an HSA
4
Don’t know
}
SKIP to 22
29025061
§>#S^¤
20
Continue with 21a
FORM
MEPS-10(S)
7
HEALTH SAVINGS ACCOUNT (HSA) - Continued
21
a. What was the MONTHLY contribution your
777
organization made to the HSA for a typical
employee with single coverage for this plan?
$
.00
Monthly HSA contribution for
single coverage
$
.00
Monthly HSA contribution for
employee-plus-one coverage
$
.00
Monthly HSA contribution for
family coverage
This amount should NOT include the amount your
organization contributed toward the plan premium.
b. What was the MONTHLY contribution your
799
organization made to the HSA for a typical
employee with employee-plus-one coverage
for this plan?
This amount should NOT include the amount your
organization contributed toward the plan premium.
c. What was the MONTHLY contribution your
778
organization made to the HSA for a typical
employee with family coverage for this plan?
This amount should NOT include the amount your
organization contributed toward the plan premium.
Report for a family of four.
HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
22
Did your organization contribute to a Health
Reimbursement Arrangement (HRA)
associated with this plan?
710
An employer can offer an HRA by setting up an account
to reimburse employees for medical expenses not
covered by health insurance.
1
Yes, contributed to an HRA
2
No, did not contribute
to an HRA
3
Don’t know
DO NOT report ICHRA or QSEHRA here.
}
SKIP to 24a
HRAs are NOT Flexible Spending Accounts (FSAs) or
Health Savings Accounts (HSAs). See definition sheet
MEPS-20(D) for more information.
23
a. Up to what dollar amount did your
779
organization contribute ANNUALLY to a
typical employee’s HRA for single coverage
for this plan?
$
.00
Annual HRA contribution for
single coverage
$
.00
Annual HRA contribution for
employee-plus-one coverage
$
.00
Annual HRA contribution for
family coverage
b. Up to what dollar amount did your
800
organization contribute ANNUALLY to a
typical employee’s HRA for employeeplus-one coverage for this plan?
29025079
This amount should NOT include the amount your
organization contributed toward the plan premium.
c. Up to what dollar amount did your
organization contribute ANNUALLY to a
typical employee’s HRA for family coverage
for this plan?
780
This amount should NOT include the amount your
organization contributed toward the plan premium.
Report for a family of four.
Continue with 24a
FORM
MEPS-10(S)
§>#Sp¤
This amount should NOT include the amount your
organization contributed toward the plan premium.
8
IN-NETWORK PAYMENTS
24
a. Was hospital care covered under this plan?
b. How much and/or what percentage of the total
bill did an enrollee pay out-of-pocket for an
inpatient hospital admission after any annual
deductible was met?
155
1
Yes - Continue with 24b
2
No - SKIP to 25a
152
$
154
.00
1
Per day
2
Per stay
Copayment paid by enrollee for
hospital admission
Report for precertified hospital admissions (if applicable).
Report for an admission at an "in-network"/participating
hospital (if applicable).
AND/OR
153
Do not include any physician charges incurred during
the hospital admission.
25
a. Was physician care covered under this plan?
b. How much and/or what percentage of the
%
218
Coinsurance paid by enrollee
1
Yes - Continue with 25b
2
No - SKIP to 26a
156
total bill did an enrollee pay out-of-pocket
for a General Practitioner office visit, with
a participating physician, after any annual
deductible was met?
$
.00
Copayment paid by enrollee for
General Practitioner office visit
AND/OR
157
%
Report for an "in-network"/participating general
practitioner, excluding preventive care visits.
771
total bill did an enrollee pay out-of-pocket
for a Specialist Physician office visit after
any annual deductible was met?
Report for an "in-network"/participating specialist,
excluding preventive care visits.
26
a. Were prescription drugs covered under this
29025087
for prescription drugs for single coverage in
this plan?
Copayment paid by enrollee for
Specialist Physician office visit
AND/OR
%
673
773
deductible that applies only to prescription
drugs?
c. What was the SEPARATE ANNUAL deductible
.00
772
health plan?
b. Did this plan have a SEPARATE ANNUAL
$
Coinsurance paid by enrollee
1
Yes - Continue with 26b
2
No
3
Don’t know
1
Yes - Continue with 26c
2
No
3
Don’t know
}
}
SKIP to 27
SKIP to 26d
774
$
.00
Separate individual prescription
drug deductible
Report "in-network" prescription deductibles for
participating pharmacies (if applicable).
Continue with 26d
FORM
MEPS-10(S)
§>#Sx¤
c. How much and/or what percentage of the
Coinsurance paid by enrollee
9
IN-NETWORK PAYMENTS - Continued
26 d. How much and/or what percentage did an
enrollee pay out-of-pocket for each type of
prescription drug covered after any annual
deductible was met?
Generic
753
$
.00
Copayment
AND/OR
754
%
762
Coinsurance
Generic not covered
Preferred brand name
755
$
.00
Copayment
AND/OR
756
%
763
Coinsurance
Preferred brand name not covered
Non-preferred brand name
757
$
.00
Copayment
AND/OR
758
%
764
Coinsurance
Non-preferred brand name not covered
Specialty
Specialty drugs are prescription medications that
are used to treat complex, chronic and often costly
conditions.
767
$
.00
Copayment
AND/OR
768
%
769
27
What was the MAXIMUM ANNUAL
out-of-pocket expense?
Specialty not covered
161
$
163
29025095
.00
Maximum out-of-pocket expense
for an individual
OR
This is often referred to as a catastrophic limit.
Report “in-network” maximum out-of-pocket
expense (if applicable).
Coinsurance
No individual maximum
788
$
.00
Maximum out-of-pocket expense
for employee-plus-one
OR
789
No employee-plus-one maximum
162
$
.00
Maximum out-of-pocket expense
for a family
OR
222
No family maximum
Continue with 28
FORM
MEPS-10(S)
§>#S¢¤
See definition sheet MEPS-20(D) for more information.
10
PLAN CHARACTERISTICS
28
Did this plan cover any of the services listed?
Yes
(1)
29
a. Did this plan cover TELEMEDICINE?
173
Chiropractic care. . . . . . . . . . . . . . . . .
736
Routine vision care for children . . . . . .
587
Routine vision care for adults. . . . . . . .
737
Routine dental care for children . . . . . .
176
Routine dental care for adults . . . . . . .
738
Mental health care . . . . . . . . . . . . . . .
182
Substance abuse treatment . . . . . . . . .
781
1
Yes
2
No
3
Don’t know
}
Don’t
No know
(2)
(3)
SKIP to 30
b. Did this plan cover either of these treatments
by TELEMEDICINE?
Yes
(1)
820
Mental health treatment. . . . . . . . . . . .
821
Substance abuse treatment . . . . . . . . .
Don’t
No know
(2)
(3)
OUT-OF-NETWORK DEDUCTIBLES AND PAYMENTS
31
29025103
32
Does this plan cover any of the costs of
non-emergency out-of-network care?
Did this plan have an out-of-network deductible?
What was the annual deductible an enrollee
paid out-of-pocket for care provided by an
out-of-network provider for different levels of
coverage?
If deductible was per overnight hospital stay, it is not
an annual deductible and should be reported under
Question 33.
801
1
Yes
2
No
3
Don’t know
1
Yes - Continue with 32
2
No - SKIP to 33
3
Don’t know - SKIP to 33
822
}
802
$
.00
Out-of-network individual
annual deductible
.00
Out-of-network
employee-plus-one
annual deductible
803
$
804
Employee-plus-one coverage not offered.
805
$
806
Skip to the bottom of
page 11 for instructions.
.00
Out-of-network family
annual deductible
Family coverage not offered.
Continue with 33
FORM
MEPS-10(S)
§>#T$¤
30
11
OUT-OF-NETWORK DEDUCTIBLES AND PAYMENTS - Continued
If this plan offered hospital care, continue with
Question 33, otherwise skip to Question 34.
33
For an out-of-network provider, how much
and/or what percentage of the total bill did
an enrollee pay out-of-pocket for an inpatient
hospital admission after any annual
deductible was met?
807
$
808
Report for precertified hospital admissions
(if applicable).
.00
1
Per day
2
Per stay
Copayment paid by enrollee for
out-of-network hospital admission
AND/OR
34
Do not include any physician charges incurred during
the hospital admission.
809
What was the maximum annual out-of-pocket
expense for care provided by an out-of-network
provider?
810
This is often referred to as a catastrophic limit.
%
$
Coinsurance paid by enrollee for
out-of-network hospital admission
.00
Out-of-network maximum
out-of-pocket expense for
an individual
OR
811
No individual maximum
812
$
.00
Out-of-network maximum
out-of-pocket expense for
employee-plus-one
OR
813
No employee-plus-one maximum
814
$
.00
Out-of-network maximum
out-of-pocket expense for
a family
OR
815
No family maximum
*** PLEASE NOTE ***
29025111
If your organization offered MORE THAN ONE health insurance
plan, please complete a Plan Information Questionnaire for each
plan that was offered, up to four plans.
To supplement your response, you may include Summary
of Benefits and Coverage or other materials describing plan
benefits and premiums in your return packet or fax to
1-800-447-4613.
FORM
MEPS-10(S)
§>#T,¤
If your organization offered only one health insurance plan,
you have completed your response to this survey.
| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2025-03-31 |
| File Created | 2025-02-25 |