Form M-1 Form for Multiple Employer Welfare Arrangements (MEWAs)

DRAFT 6-30-2011- NOTE: THIS FORM WILL BE ELECTRONIC

Form M-1

MEWA/ECE Form

This Form is Open to Public

Inspection

Form for Multiple Employer Welfare

Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs)

This filing is required to be filed under section 101(g) of the Employee Retirement Income Security Act of 1974, as amended by the Patient Protection and Affordable Care Act. See separate instructions before completing this form.

OMB No. 1210-0116

Department of Labor

Employee Benefits

Security Administration

PART I PURPOSE OF FILING

Complete as applicable:

A Identify the type of filing:

(1) Annual Report:

Calendar Year; or

Fiscal Year (specify_______); or

(2) Registration; or

(3) Origination; or

(4) Request for an extension.

Registration/Origination Options under (2) and (3):

Began Operating (link to 16)

Began Operating in an Additional State (link to 16)

Merger (link to 12)

50% increase in covered employees

Material Change

B Check here if this is a final Report ;

Check here if this is an amended Report .

C Identify the type of entity:

(1)  A Plan MEWA Reminder related to Form 5500

(2) A Non-Plan MEWA

(3)  An Entity Claiming Exception (ECE)

D Enter the most recent date the MEWA or ECE registered or was originated ­­­­________________.

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 Name and address of the administrator of the MEWA or ECE	2b Telephone number of the administrator
	2c EIN
	2d E-mail address of the administrator
3a Name and address of the entity or entities sponsoring the MEWA or ECE	3b 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 Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE.	5b Telephone number of each such person
	5c E-mail address of each such person
6a Name and address of all promoters and/or agents responsible for marketing the MEWA or ECE.	6b Telephone number of each promoter or agent
	6c E-mail address of each promoter or agent
	6d EIN of each promoter or agent
7a Name and address of any person, financial institution(s), or other entity holding assets for the MEWA or ECE	7b Telephone Number of person financial institution or entity
8 a Name and address of any actuary(ies) providing services to the MEWA or ECE.	8 b Telephone number of each actuary
	8 c E-mail address of each actuary
	8 d EIN of each actuary
9a If the MEWA or ECE has a contract with a third party administrator (TPA) the name and address of the third party administrator(s)	9b Telephone number of each TPA
	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 over the MEWA’s or ECE’s assets or over assets paid to the entity by plans or employers for the provision of benefits	10b Telephone number of each such person or entity
	10c E-mail address of each such person or entity
	10d EIN of each such person or entity
11a Name and address of any person or entity that has discretionary authority, control, or responsibility with respect to the administration of the MEWA or ECE or any benefit program offered by it	11b Telephone number of each such person or entity
	11c E-mail address of each 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 (link to question 8)

14a Are you, your entity, and/or its officers, directors, and employees covered by fiduciary liability policies? Please identify the carrier that issued the policy(ies)? Yes No (need space for issuer name)

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? Yes No If yes, please explain.

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 against any of the persons or entities listed in this Part II? Yes No If so, please list the issuing entities and the year in which each order was issued.

If filer answers “Yes” to Box 16a, they will be asked to 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.

17 Complete the following chart:

17a	17b	17c	17d	17e	17f	17g	17h	17i	17j
Enter all States where the MEWA or ECE is operating. Check if new state.	Is coverage provided?	State registration number.	Name of state agent or entity for service of process.	Is the entity a licensed health insurer in this state?	If yes to 17e, enter NAIC number.	If no to 17e. Is the entity fully insured?	If yes to 17g, enter name and NAIC number of insurer.	Does the entity purchase stop loss coverage?	If yes, enter the name and NAIC number of insurer.

18 Of the States identified in box 17a, identify those States (dropdown box) 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. _________________________________

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 Complete the following. (Note: The instructions to this form contain a Self-Compliance Tool which may be helpful in completing this item. Please read the instructions carefully before answering the following questions.)

Is this a registration or origination filing for which compliance with part 7 cannot yet be evaluated? 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? (See Part I of the Self-Compliance Tool) ………………………………....................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?(See Part II of the Self-Compliance Tool)............................................................... 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? (See Part III of the Self-Compliance tool)........................................................................................................................................ 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? (See Part IV of the Self-Compliance Tool).............................................................Yes No N/A

21e Is the coverage provided by the MEWA or ECE in compliance with Michelle’s Law (See Part V of the Self-Compliance tool).....................................................................................................................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? (See Part VI of the Self-Compliance Tool) ......................................Yes No N/A

IF MORE SPACE IS REQUIRED FOR ANY ITEM, YOU MAY ATTACH ADDITIONAL PAGES.

(SEE INSTRUCTIONS SECTION 2.3)

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 ______________________ Date ___________

Name of administrator __________________________________________________________

Address of administrator __________________________________________________