Form M-1 "Report for Multiple Employer Welfare Arrangements (Mewas) and Certain Entities Claiming Exception (Eces)"

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Download Form M-1 "Report for Multiple Employer Welfare Arrangements (Mewas) and Certain Entities Claiming Exception (Eces)"

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U.S. Department of Labor
Employee Benefits Security Administration
Room N5511
200 Constitution Avenue, NW
Washington, DC 20210
P-450
Form M-1
Report for Multiple Employer Welfare
Arrangements (MEWAs)
and Certain Entities Claiming Exception (ECEs)
This package contains the following
form and related instructions:
Form M-1
Instructions
Self-Compliance Tool
Package Form M-1
U.S. Department of Labor
Employee Benefits Security Administration
Room N5511
200 Constitution Avenue, NW
Washington, DC 20210
P-450
Form M-1
Report for Multiple Employer Welfare
Arrangements (MEWAs)
and Certain Entities Claiming Exception (ECEs)
This package contains the following
form and related instructions:
Form M-1
Instructions
Self-Compliance Tool
Package Form M-1
If you have additional questions about the Form M-1 filing requirement or the ERISA health
coverage requirements, there’s help for you.
Form M-1 Filing Requirement
(1)
For questions on completing the Form M-1, contact the Employee Benefits Security
Administration’s (EBSA’s) Form M-1 help desk at 202-693-8360.
(2)
For inquiries regarding electronic filing capability, contact the EBSA computer help desk at
202-693-8600.
(3)
For inquiries regarding the Form M-1 filing requirement, contact the Office of Health Plan
Standards and Compliance Assistance at 202-693-8335.
ERISA Health Coverage Requirements
(1)
For questions about ERISA’s health coverage requirements, contact EBSA electronically at
www.askebsa.dol.gov or by calling toll-free 1-866-444-3272.
(2)
Information including regulations, frequently asked questions, compliance assistance
materials, and other guidance regarding the requirements related to the group market reforms
added to ERISA by the Patient Protection and Affordable Care Act of 2010 can be found at
www.dol.gov/ebsa/healthreform.
(3)
EBSA’s Health Benefits Education Campaign offers compliance assistance
seminars across the country addressing a wide variety of health care issues,
including HIPAA, MHPAEA, the group market reform provisions of the Affordable Care Act,
and COBRA. For information on upcoming compliance assistance seminars,
go to www.dol.gov/ebsa/hbec.html.
The Department of Labor’s EBSA has many helpful compliance assistance publications on ERISA’s
health benefits requirements, including:
MEWAs: Multiple Employer Welfare Arrangements under the Employee Retirement Income
Security Act: A Guide to Federal and State Regulation
Health Benefits Coverage Under Federal Law
An Employer’s Guide to Group Health Continuation Coverage Under COBRA
EBSA also has many publications to assist participants and beneficiaries. EBSA’s publications are
available on the Internet at www.dol.gov/ebsa, by contacting EBSA electronically at
www.askebsa.dol.gov or by calling toll-free 1-866-444-3272.
2015
Report for Multiple Employer Welfare
OMB No. 1210-0116
Arrangements (MEWAs) and Certain
Form M-1
Entities Claiming Exception (ECEs)
Department of Labor
MEWA-ECE Form
This filing is required to be filed under section 101(g) of the
Employee Benefits
Employee Retirement Income Security Act of 1974, as amended
This Form is Open to
by the Patient Protection and Affordable Care Act.
Security Administration
Public Inspection
PART I
PURPOSE OF FILING
Complete as applicable:
A Identify the type of filing:
C Identify the type of entity:
(1)
Annual Report:
(1)
A Plan MEWA
Calendar Year; or
(2)
A Non-Plan MEWA
Fiscal Year beginning
(3)
An Entity Claiming Exception (ECE)
and ending
D Enter the most recent date the MEWA or ECE filed the
(2)
Registration
(3)
Origination
Form M-1:
(4)
Special Filing
Check the box if this is the first filing or enter the date below.
B Check here if this is a final report
Check here if this is an amended report
Check here if this is a request for an extension
PART II
CUSTODIAL & FINANCIAL INFORMATION
1a
Name and address of the MEWA or ECE
1b
Telephone number of the MEWA or ECE
1c
Employer Identification Number (EIN)
1d
Plan Number (PN)
2a
2b
Name and address of the administrator of the MEWA or ECE
Telephone number of the administrator
2c
EIN
2d
E-mail address of the administrator
3a
3b
Name and address of the entity or entities sponsoring the MEWA or ECE
Telephone number of the sponsor
3c
EIN
4a
Name and address of the agent for service of process or registered agent 4b
Telephone number of such person
4c
E-mail address of such person
5a
5b
Name and address of each member of the Board, officer, trustee, or
Telephone number of each such person
custodian of the MEWA or ECE
5c
E-mail address of such person
6a
Name and address of all promoters and/or agents responsible for
6b
Telephone number of each promoter or agent
marketing the MEWA or ECE
6c
E-mail address of such person
6d
EIN of each promoter or agent
Form M-1
Page 2
7a
Name and address of any person, financial institution(s), or other entity
7b
Telephone Number of person financial institution
holding assets for the MEWA or ECE
or entity
8a
8b
Name and address of any actuary(ies) providing services to the MEWA
Telephone number of each actuary
or ECE
8c
E-mail address of each actuary
8d
EIN of each actuary
9a
If the MEWA or ECE has a contract with a third party administrator (TPA)
9b
Telephone number of each TPA
the name and address of the third party administrator(s)
9c
E-mail address of each TPA
9d
EIN of each TPA
10a Name and address of any person or entity that has authority or control
10b Telephone number of each such person or entity
over the MEWA’s or ECE’s assets or over assets paid to the entity by
plans or employers for the provision of benefits
10c E-mail address of such person or entity
10d EIN of each such person or entity
11a Name and address of any person or entity that has discretionary
11b Telephone number of each such person or entity
authority, control, or responsibility with respect to the administration of
the MEWA or ECE or any benefit program offered by it
11c E-mail address of such person or entity
11d EIN of each such person or entity
12a Names and addresses of the MEWAs or ECEs that merged
12b Telephone number of the entities
12c EINs
12d PNs
13
Do you have an opinion from an actuary assessing the MEWA’s or ECE’s actuarial soundness, including the adequacy of
contribution rates?
Yes
No
14a Are you, your entity, and/or its officers, directors, and employees covered by fiduciary liability policies? Please identify the carrier
that issued the fiduciary liability policy(ies) in the space provided.
Yes
No
14b Are the fiduciaries of each of the plans whose participants are receiving benefits from the entity covered by a fiduciary liability
policy?
Yes
No
15
Are all assets in the possession of the MEWA or ECE maintained consistent with section 403 of ERISA and 29 CFR 2550.403a-1
and 2550.403b-1?
Yes
No If no, please explain.
16a Within the past five years, has any litigation, investigation, or other enforcement proceeding (including any administrative proceeding)
regarding any MEWA, ECE, or Group Health Plan been instituted by a Federal or State agency against the MEWA or ECE, a trustee,
or a director, owner, partner, senior manager, or officer of the sponsoring entity? If yes, please identify each litigation or enforcement
proceeding to include (if applicable): (1) the case number, (2) the date, (3) the nature of the proceedings, (4) the court, (5) all
parties (for example, plaintiffs and defendants or petitioners and respondents), and (6) the disposition.
Yes
No
16b Have any of the persons or entities listed in this Part II ever been the subject of any criminal or civil investigation or action involving
dishonesty or breach of trust or been convicted of a felony?
Yes
No If yes, please explain.
16c Have any cease and desist orders been issued by a Federal or State agency against any persons or entities listed in this
Part II?
Yes
No
If yes, please list the issuing entities and the year in which each order was issued.
Form M-1
Page 3
17
Complete the following chart:
17a
17b
17c
17d
17e
17f
17g
17h
17i
17j
Enter all
Is coverage
State
Name of
Is the entity
If yes to
If no to
If yes to
Does the
If yes to
States
provided?
registration
state agent
a licensed
17e, enter
17e, is the
17g, enter
entity
17i, enter
where the
number.
or entity for
health
NAIC
entity fully
name
purchase
the name
MEWA
service of
insurer in
number.
insured?
and NAIC
stop loss
and NAIC
or ECE is
process.
this State?
number of
coverage?
number of
operating.
insurer.
insurer.
18
Of the States identified in box 17a, identify those States in which the entity conducted 20 percent or more of its business (based
on the number of participants receiving coverage for medical care).
19
Total number of participants covered under the entity as of the last day of the year to be reported. (For Registration, Origination, or
Special Filing, report current information as of the date of the filing). ..............................................................................
PART III
INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA
20
If you answered yes to box 16a, in reference to any State or Federal litigation or enforcement proceeding
(including any administrative proceeding), check yes below if the allegation concerns a provision under
part 7 of ERISA, a corresponding provision under the Internal Revenue Code or Public Health Service Act,
a breach of any duty under Title I of ERISA if the underlying violation relates to a requirement under part 7
of ERISA, or a breach of a contractual obligation if the contract provision relates to a requirement under
part 7 of ERISA. ...........................................................................................................................................
Yes
No
21
Is this a filing for which compliance with part 7 can be evaluated?
(Note: The Self-Compliance Tool at http://www.dol.gov/ebsa/healthlawschecksheets.html may be
helpful in answering Boxes 21a-21f.) If “yes,” complete the following. ..........................................................
Yes
No
21a Is the coverage provided by the MEWA or ECE in compliance with the portability and
nondiscrimination provisions of the Health Insurance Portability and Accountability Act of 1996,
including Title I of the Genetic Information Nondiscrimination Act of 2008, and the Department of
Labor’s (Department’s) regulations issued thereunder? ...................................................................
Yes
No
N/A
21b Is the coverage provided by the MEWA or ECE in compliance with the Mental Health Parity Act
of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 and the Department’s
regulations issued thereunder? ........................................................................................................
Yes
No
N/A
21c Is the coverage provided by the MEWA or ECE in compliance with the Newborns’ and Mothers’
Health Protection Act of 1996 and the Department’s regulations issued thereunder? .....................
Yes
No
N/A
21d Is the coverage provided by the MEWA or ECE in compliance with the Women’s Health and
Cancer Rights Act of 1998? ..............................................................................................................
Yes
No
N/A
21e Is the coverage provided by the MEWA or ECE in compliance with Michelle’s Law? .......................
Yes
No
N/A
21f Is the coverage provided by the MEWA or ECE in compliance with the Patient Protection and
Affordable Care Act of 2010 and the Department’s regulations issued thereunder that are
applicable as of the date signed at the bottom of this form? ............................................................
Yes
No
N/A
ATTACHMENTS
SIGNATURE
Under penalty of perjury and other penalties set forth in the instructions, I declare that I have examined this report, including any
accompanying attachments, and to the best of my knowledge and belief, it is true and correct. Under penalty of perjury and other
penalties set forth in the instructions, I also declare that, unless this is an extension request, this report is complete.
Signature of Administrator:
Address of Administrator:
Date: