"Multiple Employer Welfare Arrangements (Mewa) Initial Application for Licensure and Initial Application Update" - Delaware

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Multiple Employer Welfare Arrangements (MEWA)
Initial Application for Licensure and Initial Application Update
Only use this form for an initial application and for an update to the initial application made pursuant to 18 DE
Admin. Code § 1405-4.3 (which requires that if, subsequent to an initial application, changes occur so that the
information contained in the filing is no longer accurate, the MEWA, association, or intermediary that made the filing
shall, within fifteen days of the date the change is effective, file the changes with the Department), when the update is
made within the first year of being a licensed Association or MEWA.
Please complete all fields to avoid delay in processing. Attach additional pages as
needed.
☐ This is an initial application
☐ This is an update to an initial application
(place an “X” beside the information that is being updated and
the date on which the information changed)
Information
Date on
updated
which
with this
information
submission?
changed
If yes, place
“X” here.
__/__/____
1. Name of Association or MEWA: __________________________________
2.
Names and business addresses of all principals, officers, directors, and
trustees
of the Association or
MEWA:
__/__/____
a.
_______________________________________________________
b.
_______________________________________________________
__/__/____
c.
_______________________________________________________
__/__/____
d.
_______________________________________________________
__/__/____
e.
_______________________________________________________
__/__/____
3.
Names and addresses of the employer members:
__/__/____
a.
_______________________________________________________
__/__/____
b.
_______________________________________________________
__/__/____
c.
_______________________________________________________
d.
_______________________________________________________
__/__/____
e. _______________________________________________________
__/__/____
Initial Application | 1
Multiple Employer Welfare Arrangements (MEWA)
Initial Application for Licensure and Initial Application Update
Only use this form for an initial application and for an update to the initial application made pursuant to 18 DE
Admin. Code § 1405-4.3 (which requires that if, subsequent to an initial application, changes occur so that the
information contained in the filing is no longer accurate, the MEWA, association, or intermediary that made the filing
shall, within fifteen days of the date the change is effective, file the changes with the Department), when the update is
made within the first year of being a licensed Association or MEWA.
Please complete all fields to avoid delay in processing. Attach additional pages as
needed.
☐ This is an initial application
☐ This is an update to an initial application
(place an “X” beside the information that is being updated and
the date on which the information changed)
Information
Date on
updated
which
with this
information
submission?
changed
If yes, place
“X” here.
__/__/____
1. Name of Association or MEWA: __________________________________
2.
Names and business addresses of all principals, officers, directors, and
trustees
of the Association or
MEWA:
__/__/____
a.
_______________________________________________________
b.
_______________________________________________________
__/__/____
c.
_______________________________________________________
__/__/____
d.
_______________________________________________________
__/__/____
e.
_______________________________________________________
__/__/____
3.
Names and addresses of the employer members:
__/__/____
a.
_______________________________________________________
__/__/____
b.
_______________________________________________________
__/__/____
c.
_______________________________________________________
d.
_______________________________________________________
__/__/____
e. _______________________________________________________
__/__/____
Initial Application | 1
4.
Names and addresses of trustees or other persons responsible for the
MEWA's or the Association's operation:
__/__/____
a.
_______________________________________________________
b.
_______________________________________________________
__/__/____
c.
_______________________________________________________
__/__/____
d.
_______________________________________________________
__/__/____
e. _______________________________________________________
__/__/____
5. List the contact information for where communications are to be received
for the Company:
__/__/____
a.
Mailing address: _________________________________________
__/__/____
b.
Email address: __________________________________________
__/__/____
c. Telephone number: ______________________________________
6.
Set forth the eligibility requirements for membership in the Association or
MEWA (add additional pages if more space is needed):
__/__/____
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
7.
Are fees charged for membership in the Association or MEWA;
YES ☐ or NO ☐.
__/__/____
If yes, please provide details of the fee structure, including amounts charged:
________________________________________________________________
8. Are the Association or MEWA’s benefits or coverage fully insured;
__/__/____
YES ☐ or NO ☐
If no, please provide explanation:
____________________________________________
9. List the
name of the insurer that insures the Association or MEWA:
__/__/____
_______________________________________________________
Initial Application | 2
10.
Does the Association or MEWA meet all of the following requirements of a
“bona fide association” set forth in
18 Del. C. §
3506(a)?
__/__/____
a. Has been actively in existence for at least 5 years YES ☐ or NO ☐
__/__/____
b. Has been formed and maintained in good faith for purposes other
than obtaining insurance and does not condition membership on the
purchase of association-sponsored insurance YES ☐ or NO ☐
__/__/____
c. Does not condition membership in the association on any health
status-related factor relating to an individual (including an employee
of an employer or a dependent of an employee) and clearly so states
in all membership and application materials YES ☐ or NO ☐
d. Makes health insurance coverage offered through the association
__/__/____
available to all members regardless of any health status-related
factor relating to such members (or individuals eligible for coverage
through a member) and clearly so states in all marketing and
application materials YES ☐ or NO ☐
e. Does not make health insurance coverage offered through the
__/__/____
association available other than in connection with a member of the
association and clearly so states in all marketing and application
materials YES ☐ or NO ☐
f. Provides and annually updates information necessary for the
__/__/____
Commissioner to determine whether or not an association meets the
definition of a bona fide association before qualifying as a bona fide
association for the purposes of this chapter. YES ☐ or NO ☐
If no, please provide an explanation:
_____________________________________________________________
Initial Application | 3
11. Is the insurance policy offered by the Association or MEWA in compliance
with the following requirements as set forth in
18 Del. C. §
3506(b)?
__/__/____
a. The policy may insure members of such association or associations,
employees thereof or employees of members or 1 or more of the
preceding or all of any class or classes thereof for the benefit of
persons other than the employer YES ☐ or NO ☐
b. The premium for the policy shall be paid from funds contributed by
__/__/____
the association or associations or by the employer members, or by
both, or from funds contributed by the covered persons or from both
the covered persons and the association, associations or employer
members. YES ☐ or NO ☐
c. A policy on which no part of the premium is to be derived from
__/__/____
funds contributed by the covered persons specifically for their
insurance must insure all eligible persons, except those who reject
such coverage in writing. YES ☐ or NO ☐
If no, please provide an explanation:
________________________________________________________________
12. Describe the Association or MEWA’s membership requirements:
__/__/____
_____________________________________________________________
__/__/____
13. List the names, addresses, and qualifications of persons who will solicit,
negotiate, procure, or effect applications for coverage with the association
or
MEWA:
Name: _______________________________________________________
Address: _____________________________________________________
Qualifications_________________________________________________
Name: _______________________________________________________
Address: _____________________________________________________
Qualifications_________________________________________________
Initial Application | 4
__/__/____
14. List the names and addresses of all administrators and organizations,
including third party administrators or intermediaries, responsible for the
operation of the Association or MEWA that complies with the following:
__/__/____
• The Association or MEWA contact shall be the person responsible
for filing all applicable forms and changes in information with the
Department:
Name: ___________________________________________
Address: _________________________________________
Role: TPA ☐, Intermediary ☐, Other ☐. If other, please
specify:
Name: ___________________________________________
Address: _________________________________________
Role: TPA ☐, Intermediary ☐, Other ☐. If other, please
specify: __________________________________________
• The regulatory contact shall be the person responsible for receiving
__/__/____
notice of laws regulations, bulletins, and the like that may affect
the plan. Complete and attach
Form
D2.
Name: ___________________________________________
Address: _________________________________________
__/__/____
15. Does the insurer offering the health benefit plan to the association or a
MEWA shall guarantee acceptance of all persons within the association or
MEWA and their dependents as required by
18 DE Admin. Code §
7.5?
YES ☐ or NO ☐
__/__/____
16. Does the health benefit plan provide all of the benefits listed in
18 DE
8.0? YES ☐ or NO ☐
Admin. Code §
__/__/____
17. Does the health benefit plan meet all of the membership requirements of
18
9.0? YES ☐ or NO ☐
DE Admin. Code §
18. Does the health benefit plan comply with the notice requirements of
18 DE
10.0? YES ☐ or NO ☐
__/__/____
Admin. Code §
19. Does the health benefit plan comply with the enrollment requirements in
18
3571J? YES ☐ or NO ☐
__/__/____
DE Admin. Code § 11.0
and
18 Del. C. §
Initial Application | 5