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

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.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa or by calling toll-free 1-866-444-3272.

2. Information, including regulations, frequently asked questions (FAQs), 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/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for- employers-and-advisers

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/agencies/ebsa/about-ebsa/our-activities/programs-and- initiatives/outreach-and-education/hbec.

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

• Reporting and Disclosure Guide for Employee Benefit Plans

EBSA also has many publications to assist participants and beneficiaries. EBSA’s publications are available on the Internet at www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource- center/publications, by contacting EBSA electronically at www.dol.gov/agencies/ebsa/about- ebsa/ask-a-question/ask-ebsa or by calling toll-free 1-866-444-3272.

2017 Form M-1 MEWA-ECE Form This Form is Open to Public Inspection	Report 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.	OMB No. 1210-0116 Department of Labor Employee Benefits Security Administration

PART I PURPOSE OF FILING

Complete as applicable:

1. Identify the type of filing:

   1. Annual Report:

 Calendar Year; or

 Fiscal Year beginning and ending

2. Registration

Date entity began operatingEnter Date: _________________

3. Origination Enter Date: __________

4. Special Filing Enter Date: __________

1. (1) Check here if this is a final report 

2. Check here if this is an amended report 

3. Check here if this is a request for an extension 

3. Identify the type of entity:

   1. A Plan MEWA

   2.  A Non-Plan MEWA

   3.  An Entity Claiming Exception

4. Enter the most recent date the MEWA or ECE filed Form M-1:

 Check the box if this is the first filing or enter the date below.

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 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 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 holding assets for the MEWA or ECE	7b	Telephone number of person financial institution or entity
8a Name and address of any actuary(ies) providing services to the MEWA or ECE	8b	Telephone number of each actuary
	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), the name and address of the TPA(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 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 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 If “yes” is checked, see instructions regarding required attachment.

14a Are 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 office 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 a separate row for each state in which the entity operates in the following chart. (Note: Only entities that provide medical care (within the meaning of ERISA section 733(a)(2)) are required to file the Form M-1.):

    17a	17b	17c	17d	17e	17f	17g	17h	17i	17j
    Enter all States where the MEWA or ECE is operating.	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 to 17i, enter the name and NAIC number of 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

17. 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

17. Is this the MEWA subject to a filing for which compliance with part 7 of ERISA on the date of the filingcan be evaluated?

(Note: The Self-Compliance Tool at https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan- administration-and-compliance/health-plans/hbec/checksheets.html may be

helpful in answering Boxes 21a-21f.) If “yes,” complete the following........................................................... Yes  No

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

 Yes No N/A

21d Is the coverage provided by the MEWA or ECE compliance with the Women’s Health and Cancer Rights Act of 1998?..............................................................................................................

21e Is the coverage provided by the MEWA or ECE in compliance with Michelle’s Law?.......................

Yes No  N/A

21c Is the coverage provided by 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

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

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 thereunder? ..............................................................................

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:

Department of Labor

Employee Benefits Security Administration

Instructions for Form M-1

Report for Multiple Employer Welfare Arrangements (MEWAs) and

Certain Entities Claiming Exception (ECEs)

About the Form M-1

The Form M-1 is used to report information concerning a multiple employer welfare arrangement (MEWA) that provides benefits consisting of medical care (within the meaning of ERISA section 733(a)(2)) and any entity claiming exception (ECE). Reporting is required pursuant to ERISA sections 101(g), 104(a), 505 and 734 of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, and 29 CFR 2520.101-2 and 103-

1.

You must file the Form M-1 electronically. You cannot file a paper Form M-1 by mail or other delivery service. Your Form M-1 will be initially screened electronically so it is in the filer’s best interest that the responses accurately reflect the circumstances they were designed to report.

For more information, see the instructions for Electronic Filing Requirement and the Form M-1 filing system at www.askebsa.dol.gov/mewa.

The Department of Labor, EBSA, is committed to working together with administrators to help them comply with

this filing requirement. If you have any questions (such as whether you are required to file this report) or if you need any assistance in completing this report, please call the EBSA Form M-1 help desk at 202-693-8360.

Changes to Note

Administrative Penalties. The instructions have been updated to reflect that the maximum penalty for a MEWA administrator who fails or refuses to file a complete or accurate Form M-1 report has been increased to $1,55827 a day. The penalty is applicable only to civil penalties assessed after January 213, 20187, whose associated violation(s) occurred after November 2, 2015. 82 FR 5373 (Jan.18, 2017). Because the

Federal Civil Penalties Inflation Adjustment Improvements Act of 2015 (Pub. L. No. 114-74; 129 Stat. 599) requires the penalty amount to be adjusted annually for inflation no later than January 15 of each year, be sure to check for any possible adjustments of the maximum penalty amount that may have been published in the Federal Register after the Form M-1 and instructions have been published.

Actuary Opinion- Filers who indicate (in question 13) that there is an opinion from an actuary assessing the MEWA’s or ECE’s soundness, are now required to attach the actuarial opinion to their M-1 filing.

SECTION 1: Who Must File

General Rules

The administrator of a MEWA must file this report regardless of whether the entity is a group health plan.

The administrator of an ECE must file this report during the first three years after the ECE is originated.

Table of Contents

SECTION 1: Who Must File 1

General Rules 1

Exceptions to the Filing Requirements 2

SECTION 2: When to File 2

Annual Report General Rule 2

Registration, Origination or Special Filings 3

Material Change 3

Extensions of Time 3

Section 3: Electronic Filing 4

How to File 4

Amended Report 4

Final Report 4

Attaching Additional Pages 4

Penalties 4

Signature and Date 5

SECTION 4: Line-by-Line Instructions 5

Part I – Purpose of Filing 5

Part II – Custodial & Financial Information 5

Part III– Information for Compliance

with Part 7 of ERISA 8

Paperwork Reduction Act Notice 11

A MEWA that is required to file an M-1 is an employee welfare benefit plan or other arrangement that provides benefits consisting of is established or maintained for the purpose of offering or providing medical care (within the meaning of ERISA section n 733(a)(2)) to the employees of two or more employers (including one or more self-employed individuals), or to their beneficiaries, except that the term does not include any such plan or other arrangement that is established or maintained under or pursuant to one or more agreements that the Secretary finds to be collective bargaining agreements, by a rural electric cooperative, or by a rural telephone cooperative association. See ERISA section 3(40). (Note: Many States regulate entities as MEWAs using their own State definition of the term. Whether or not an entity meets a State’s definition of a MEWA for purposes of regulation under State law is a matter of State law.)

An entity claiming exception or “ECE” is an entity that claims it is not a MEWA on the basis that the entity is established or maintained pursuant to one or more agreements that the Secretary finds to be collective bargaining agreements within the meaning of section 3(40) (A)(i) of ERISA and 29 CFR 2510.3–40.

IMPORTANT:

The administrator of a MEWA must file this report regardless of whether the entity is a group health plan.

The administrator of an ECE must file this report during the first three years after the ECE is originated.

If a MEWA also constitutes an “employee welfare benefit plan” under ERISA, the MEWA must file a Form 5500 Annual Return/Report (and required Schedules and attachments) with the Department. www.efast.dol.gov https://www.efast.dol.gov/welcome.html .

Use the same name, employer identification number (EIN), and other identifying information on the Form M-1 and on the Form 5500.

TIP ‘‘Group insurance arrangements’’ (non-plan entities that provide benefits to the employees of two or more unaffiliated employers (not in connection with a multiemployer plan or a collectively-bargained multiple-employer plan), fully insure one or more welfare plans of each participating employer, use a trust or other entity as the holder of the insurance contracts, and use a trust as the conduit for payment of premiums to the insurance company) may choose to file a Form 5500 Annual Return/Report. If a consolidated Form 5500 report for all the plans in the arrangement is filed in accordance with Department of Labor regulations at 29 CFR 2520.104- 43, those plans participating in a GIA are exempt from the requirement to file a Form5500. See Form 5500 instructions.

Use the same name, employer identification number (EIN), and other identifying information on the Form M-1 and on the Form 5500.

For more information on MEWAs, visit EBSA’s Web site at www.dol.gov/agencies/ebsa or call the EBSA toll-free hotline at 1-866-444-3272 and ask for the booklet entitled MEWAs: Multiple Employer Welfare Arrangements under the Employee Retirement Income Security Act (ERISA): A Guide to Federal and State Regulation. For information on State MEWA regulation, contact your State Insurance Department.

Exceptions to the Filing Requirements

In no event is reporting required by the administrator of a MEWA or ECE if the MEWA or ECE meets any of the following conditions:

1. It is licensed or authorized to operate as a health insurance issuer in every State in which it offers or provides coverage for medical care to employees. The term “health insurance issuer” or “issuer” is defined, in pertinent part, in §2590.701-2 of the Department’s regulations as “an insurance company, insurance service, or insurance organization (including an HMO) that is required to be licensed to engage in the business of insurance in a State and that is subject to State law which regulates insurance . . . . Such term does not include a group health plan.”

2. It provides coverage that consists solely of excepted benefits, which are not subject to part 7 of ERISA.

(However, if the MEWA or ECE provides coverage that consists both of excepted benefits and other benefits for medical care that are not excepted benefits, the administrator of the MEWA or ECE is required to file the Form M-1.)

3. It is a group health plan that is not subject to ERISA, including a governmental plan, church plan, or plan maintained only for the purpose of complying with workers’ compensation laws within the meaning of sections 4(b)(1), 4(b)(2), or 4(b)(3) of ERISA, respectively. In general, a group health plan means an employee welfare benefit plan to the extent that the plan provides medical care to employees (including both current and former employees) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. See ERISA section 733(a) and 29 CFR 2590.701-2.

4. It provides coverage only through group health plans that are not covered by ERISA, including governmental plans, church plans, and plans

maintained only for the purpose of complying with workers’ compensation laws within the meaning of sections 4(b)(1), 4(b)(2), or 4(b)(3) of ERISA, respectively (or other arrangements not subject to ERISA, such as health insurance coverage offered to individuals other than in connection with a group health plan, known as individual market coverage).

In addition, in no event is reporting required by the administrator of an entity that meets the definition of a MEWA or ECE because one or more of the following is true:

1. It provides coverage to the employees of two or more trades or businesses that share a common control interest of at least 25 percent at any time during the plan year, applying principles similar to the principles applied under section 414(c) of the Internal Revenue Code.

2. It provides coverage to the employees of two or more employers due to a change in control of businesses (such as a merger or acquisition) that occurs for a purpose other than avoiding Form M-1 filing and is temporary in nature (i.e., it does not extend beyond the end of the plan year following the plan year in which the change in control occurs).

( 3) It provides coverage to persons (excluding spouses and dependents) who are not employees or former employees of the plan sponsor, such as nonemployee members of the board of directors or independent contractors, and the number of such persons who are not employees or former employees does not exceed one percent of the total number of employees or former employees covered under the arrangement, determined as of the last day of the year to be reported or determined as of the 60th day following the date the MEWA or ECE began operating in a manner such that a filing is required pursuant to 29 CFR 2590.101-2(e)(1)(i), (2), or (3).

SECTION 2: When to File

Annual Report General Rule

For purposes of these instructions, an “annual report” refers to the annual Form M-1 filing required of all MEWAs and certain ECEs. The annual report must be filed no later than March 1 following any calendar year for which a filing is required (unless March 1 is a Saturday, Sunday, or Federal holiday, in which case the form must be filed no later than the next business day). Filing the Form M-1 annual report, does not satisfy the requirement under ERISA section 104 and 29 CFR 2520.103-1 to file an annual report (Form 5500 series).

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The administrator of an ECE must file an annual report if the ECE was last originated at any time within 3 years before the annual filing due date. An ECE may be originated more than once.

No annual report is required if, between October 1 and December 31, the MEWA or ECE experiences an origination, special filing, or registration event and makes a subsequent, timely filing.

The administrator of a MEWA or ECE that is required to file must file the annual report using the previous calendar year’s information. (For example, for a filing due by March 1, 2018, calendar year 2017 information should be used.) However, the administrator of a MEWA or ECE may report using fiscal year information if the administrator of the MEWA or ECE has at least 6 continuous months of fiscal year information to report. (Thus, for example, for a filing that is due by March 1, 2018, fiscal year 2017 information may be used if the administrator has at least 6 continuous months of fiscal year 2017 information to report.)

Registration, Origination, or Special Filings

Additional filings are necessary when a MEWA or ECE experiences certain events, beginning on or after July 1, 2013.

A MEWA must file a Form M-1 pursuant to §2520.101- 2 of the Department’s regulations when any of the following registration events occur:

1. The MEWA first begins operating with regard to the employees of two or more employers (including one or more self-employed individuals);

2. The MEWA begins knowingly operating in any additional State;

3. The MEWA begins operating following a merger with another MEWA;

4. The number of employees receiving coverage for medical care under the MEWA is at least 50 percent greater than the number of such employees on the last day of the previous calendar year; or

5. The MEWA experiences a material change as defined by these instructions.

Event 1 requires a registration filing 30 days prior to the event, while events 2-5 require a registration filing within 30 days of the event occurring. A MEWA may be required to register more than once in a calendar year.

A MEWA that is required to make a registration filing must use the most recently updated Form M-1 that is available to do so. (For example, a registration filing due by November 1, 2018 would use the 2017 Form M-1.)

An ECE must file a Form M-1 pursuant to §2520.101-2 of the Department’s regulations when any of the following origination events occur:

1. The ECE first begins operating with regard to the employees of two or more employers (including one or more self-employed individuals);

2. The ECE begins operating following a merger with another ECE (unless all of the ECEs that participate in the merger previously were last originated at least three years prior to the merger); and,

3. The number of employees receiving coverage for medical care under the ECE is at least 50 percent greater than the number of such employees on the last day of the previous calendar year (unless the increase is due to a merger with another ECE under which all ECEs that participate in the merger were last originated at least three years prior to the merger).

Event 1 requires an origination event filing 30 days prior to the event, while events 2 and 3 require a filing within 30 days of the event occurring.

An ECE that is required to make an origination filing must use the most recently updated Form M-1 that is available to do so. (For example, an origination filing due by November 1, 2018 would use the 2017 Form M-1.)

An ECE must also file a Form M-1 when any of the following special filing events occur within the three- year filing period following an origination event:

1. The ECE begins knowingly operating in any additional State; or

2. The ECE experiences a material change as defined by these instructions.

Special event filings are due within 30 days of the event occurring. An ECE may be required to file the Form M-1 more than once in a calendar year.

An ECE that is required to make a special filing must use the most recently updated Form M-1 that is available to do so. (For example, a special filing due by November 1, 2018 would use the 2017 Form M-1.)

For purposes of the Form M-1, “operating” means “any activity including but not limited to marketing, soliciting, providing, or offering to provide benefits consisting of medical care.”

Material Change

If any of the custodial or financial information reported on Part II of this Form M-1 changes, such change is considered a material change and requires the MEWA or ECE to submit a new Form M-1 filing. Note, ECEs must only file when a material change occurs during the three-year filing period following an origination event. A material change will not restart the calculation of that period.

Extensions of Time

A one-time extension of time to file will automatically be granted if the administrator of the MEWA or ECE

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requests an extension. To request an extension, the administrator must: (1) check box B(3) in Part I, and complete the rest of Part I as it applies to the MEWA or ECE; (2) complete boxes 1a-d, 2a-d, and 3a-c in Part II; (3) electronically sign, date, and provide the administrator’s name at the end of the form; and (4) electronically file this request for extension no later than the normal due date for the Form M-1. In such a case, the administrator will have an additional 60 days to file a completed Form M-1. A copy of this request for extension must be attached to the completed Form M-1 when filed.

SECTION 3: Electronic Filing

How to File

The Form M-1 must be filed electronically with the Department of Labor by going to www.askebsa.dol.gov/mewa.

Your entries must be in the proper format in order for the electronic system to process your filing. For example, if a question requires you to enter a numerical account number, you cannot enter a word. To reduce the possibility of correspondence and penalties:

Complete all lines on the Form M-1 unless otherwise specified.

Do not enter “N/A” or “Not Applicable” on the Form M-1 unless specifically permitted. “Yes” or “No” questions on the Form M-1 cannot be left blank, unless specifically permitted. Answer either “Yes” or “No,” but not both.

Do not enter social security numbers in response to questions asking for an employer identification number (EIN). Because of privacy concerns, the inclusion of a social security number on the Form M-1 or on an attachment that is open to public inspection may result in the rejection of the filing.

Amended Report

To correct errors and/or omissions on a previously filed Form M-1, submit a completed Form M-1 indicating the filing is an amended report in Part I, Item B(2).

Final Report

If the administrator of a MEWA or ECE does not intend to file a Form M-1 next year, the filing should be the final report. For example, if this is the third filing following an origination for an ECE, or if a MEWA has ceased operations, the administrator

should indicate this is the final report in Part I, Item B(1).

Attaching Additional Pages

If additional pages are necessary to provide the required information, attachments may be uploaded to your electronic filing using the “Attachments” tab. Instructions are provided on the filing website.

Penalties

In the event of a failure to file a Form M-1, failure to file a complete Form M-1 or late Form M-1 filings, a penalty may apply of up to $1,527 a day for each day that the administrator of the MEWA fails or refuses to file a complete and accurate report. See ERISA section 502(c)(5), 29 CFR 2560.502c-5 and the Federal Civil Penalties Inflation Adjustment Act of 1990, as amended by the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (Inflation Adjustment Act). Pub. L. No. 114-74; 129 Stat. 599. The Inflation Adjustment Act requires agencies to adjust the levels of civil monetary penalties with an initial catch-up adjustment, followed by annual adjustments for inflation. See Department of Labor Federal Civil Penalties Inflation Adjustment Act Annual Adjustment for 2017. 82 FR 5373 (Jan.18, 2017). The penalty listed above is applicable only to civil penalties assessed after January 13, 2017, whose associated violation(s) occurred after November 2, 2015. Because the Inflation Adjustment Act requires the penalty amount to be adjusted annually for inflation no later than January 15 of each year, be sure to check for any possible adjustments of the maximum penalty amount that may have been published in the Federal Register after the Form M-1 and instructions have been published. Any changes to ERISA Title I penalty amounts will be posted on the Employee Benefits Security Administration’s website

ERISA section 521(a) authorizes the Secretary of Labor to issue an ex parte cease and desist order if it appears to the Secretary that the alleged conduct of a MEWA is fraudulent, or creates an immediate danger to the public safety or welfare, or is causing or can reasonably be expected to cause significant, imminent, and irreparable public injury. ERISA section 521(e) authorizes the Secretary to issue a summary seizure order if it appears that a MEWA is in a financially hazardous condition.

In addition, certain other penalties may apply.

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Signature and Date

For purposes of Title I of ERISA, the administrator is required to file the Form M-1. The administrator or, if the administrator is an entity, a person authorized to sign on behalf of the administrator must electronically sign the Form M-1 and submit it to the electronic filing system. If the administrator does not electronically sign a filing, the filing status will indicate that there is an error with your filing.

To obtain an electronic signature, go to www.askebsa.dol.gov/mewa and register as a signer. You will be provided with a User ID and Password. Both the User ID and Password are needed to sign the Form M-1.

Electronic signatures on annual returns/reports filed are governed by the applicable statutory and regulatory requirements.

The system will prevent the submission of any filing that does not include all required information. A completed filing will generate a receipt confirmation code. The administrator must keep a copy of the receipt as well as any attachments on file as part of its records as required by section 107 of ERISA.

Note: Even after submission, your filing may be subject to further, detailed review by DOL and may be deemed deficient based upon this review. See Penalties section.

Detailed information on electronic filing is available at www.askebsa.dol.gov/mewa. If you have questions about using or completing the Form M-1, please contact the Form M-1 Help Desk at 202-693-8360.

SECTION 4: Line-by-Line Instructions

Important: “Yes/No” questions must be marked “Yes” or “No,” but not both. “N/A” is not an acceptable response unless expressly permitted in the instructions to that line.

Note: For purposes of the Form M-1, an “annual report” is the annual filing made by all MEWAs by March 1 and for ECEs, the annual filing made by March 1 for the first three years after an origination.

Part I – Purpose of Filing

Item A: Check the appropriate box indicating whether this filing is an annual report, registration, origination, or special filing. If it is an annual report, check the appropriate box indicating whether calendar year or fiscal year information is being used to complete the form. If fiscal year information is being used, specify the month, day and year corresponding to the information. If it is a registration, origination, or special filing, check the

appropriate box (or boxes) indicating the reason (or reasons) for the filing,.

If the filing is a registration filing and, indicate the date of the registration, origination, or occurrence of the reason requiring a special filing. the entity will begin operating in a State. “Operating” means “any activity including but not limited to marketing, soliciting, providing, or offering to provide benefits consisting of medical care.”

Item B: Check the appropriate box identifying if the report is a final report, an amended report, or a request for extension. If this is not an amended report, final report, or request for extension, skip to Item C.

Item C: Check the appropriate box identifying whether the filing entity is a plan MEWA (a MEWA within the meaning of ERISA section 3(40) that is also an employee welfare benefit plan within the meaning of ERISA section 3(3)), a non-plan MEWA or an ECE.

Note: If you check the box identifying the entity as a Plan MEWA, please note that all plan MEWAs are also required to file the Form 5500 Annual Return/Report of Employee Benefit Plan, regardless of size or type of funding. For more information on the Form 5500 you can access www.efast.dol.gov or call toll free at 1-866-463-3278.

Item D: Enter the date of the most recent MEWA or ECE Form M-1 filing. Indicate in the check box if this is the MEWA or ECE’s first time filing a Form M-1.

Part II – Custodial & Financial Information

Important: Filers should report the same EIN fFor those partiesentities and individuals that are required to be reported in Boxes 1a-11a and also reported on the Form 5500 (andincluding its Schedules and Attachments) for the same filing entity use the same name, EIN, and other identifying information.

Box 1a and 1b: Enter the name, address, and telephone number of the MEWA or ECE.

Box 1c: Enter the EIN used by the MEWA or ECE to the Department of Labor or the Internal Revenue Service. An EIN is a nine-digit employer identification number (for example, 00-1234567) that has been assigned by the IRS. Entities that do not have an EIN should apply for one on Form SS-4, Application for Employer Identification Number, as soon as possible.

You can obtain Form SS-4 by calling 1-800-829-4933 or at the IRS Web site at www.irs.gov. EBSA does NOT issue EINs. If the MEWA or ECE does not have any EINs associated with it, leave Box 1c blank.

Box 1d: Enter the plan number used by the MEWA or ECE. A plan number or “PN” is a three-digit number assigned to a plan or other entity by an employer or plan administrator. For plans or other entities providing welfare benefits, the first plan number should be number 501 and additional plans should be numbered consecutively. For MEWAs or ECEs that file a Form 5500 Annual Return/ Report of Employee Benefit Plan (Form 5500), the same PN should be used for the Form M-1. (For more information on the Form 5500 you can access www.efast.dol.gov. www.efast.dol.gov/welcome.html or call toll-free at 1-866-463-3278.) If the MEWA or ECE does not have any PNs associated with it, leave Box 1d blank.

For Boxes 1c and 1d, list only EINs and PNs used by the MEWA or ECE itself and not those used by group

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health plans or employers that purchase coverage through the MEWA or ECE.

Box 2a and 2b: Enter the name, address, and telephone number of the administrator of the MEWA or ECE. The term “administrator” is defined in §2520.101- 2(b)(1) of the Department’s regulations as:

1. The person specifically so designated by the terms of the instrument under which the MEWA or ECE is operated;

2. If the MEWA or ECE is a group health plan and the administrator is not so designated, the plan sponsor (as defined in section 3(16)(B) of ERISA); or

3. In the case of a MEWA or ECE for which an administrator is not designated and a plan sponsor cannot be identified, jointly and severally, the person or persons actually responsible (whether or not so designated under the terms of the instrument under which the MEWA or ECE is operated) for the control, disposition, or management of the cash or property received by or contributed to the MEWA or ECE, irrespective of whether such control, disposition, or management is exercised directly by such person or persons or indirectly through an agent, custodian, or trustee designated by such person or persons.

Box 2c: Enter any EIN used by the administrator in reporting to the Department of Labor or the Internal Revenue Service. For this purpose, use only an EIN associated with the administrator as a separate entity. Do not use any EIN associated with the MEWA or ECE itself.

Box 2d: Enter the e-mail address of the administrator of the MEWA or ECE.

Boxes 3a through 3c: Enter the name, address, and telephone number of the entity or entities sponsoring the MEWA or ECE, and any EIN used by the sponsor in reporting to the Department of Labor or the Internal Revenue Service. For purposes of the Form M-1, the sponsor is either:

1. the plan sponsor as defined in ERISA section 3(16)(B) if the MEWA or ECE is a group health plan; or

2. the entity that establishes or maintains the MEWA or ECE if the MEWA or ECE is not a group health plan.

For this purpose, use only an EIN associated with the sponsor. Do not use any EIN associated with the MEWA or ECE itself. If the filing entity does not have a sponsor, leave Boxes 3a through 3c blank and skip to Box 4a.

Boxes 4a through 4c: Enter the name, address, telephone number, and e-mail address of the agent for service of process or registered agent on behalf of the MEWA or ECE. An agent for service of process or registered agent is a person appointed by

the MEWA or ECE to receive legal notices on behalf of the MEWA or ECE.

Boxes 5a through 5c: Enter the name, address, telephone number, and email address of each member of the Board of Directors, as well as each officer, trustee, or custodian of the MEWA or ECE. You may attach additional pages if necessary to provide all required information on each board member. If the filing entity does not have a Board of Directors or officer, trustee or custodian, leave Boxes 5a through 5c blank and skip to Box 6a.

Boxes 6a through 6d: Enter the name, address, telephone number, and email address of each promoter or agent responsible for marketing the MEWA or ECE, and any EIN used by such in reporting to the Department of Labor or the Internal Revenue Service. For this purpose, use only an EIN associated with the promoter or agent.

Do not use any EIN associated with the MEWA or ECE itself. If there is no such promoter or agent, leave Boxes 6a through 6d blank and skip to Box 7a.

Boxes 7a through 7b: Enter the name, address, and telephone number of each person, financial institution(s), or other entity holding assets for the MEWA or ECE.

Boxes 8a through 8c: Enter the name, address, telephone number, and e-mail address of each actuary or actuaries providing services to the MEWA or ECE. An actuary is a professional who examines risk and is in charge of evaluating the likelihood of future events. An actuary should be an associate or fellow of the Society of Actuaries and a member of the American Academy of Actuaries and be able to judge the actuarial soundness of the arrangement. Boxes 8a through 8c are mandatory if you answer “Yes” to Box 13.

Box 8d: Enter any EIN used by the actuary in reporting to the Department of Labor or the Internal Revenue Service. For this purpose, use only an EIN associated with the actuary. Do not use any EIN associated with the MEWA or ECE itself. If there is no actuary, leave Boxes 8a through 8d blank and skip to Box 9a.

Boxes 9a through 9d: Enter the name, address, telephone number, and e-mail address of each third party administrator (TPA) providing services to the MEWA or ECE, and any EIN used by such in reporting to the Department of Labor or the Internal Revenue Service. For this purpose, use only an EIN associated with the TPA. Do not use any EIN associated with the MEWA or ECE itself. If there is no such TPA, leave Boxes 9a through 9d blank and skip to Box 10a.

Boxes 10a through 10d: Enter the name, address, telephone number, and email address of each person or entity that has authority or control of the MEWA’s or ECE’s assets, or of assets paid by plans or employers to the MEWA or ECE, and any EIN used by such in reporting to the Department of Labor or the Internal Revenue Service. For this purpose, use only an EIN

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associated with the person or entity. Do not use any EIN associated with the MEWA or ECE itself.

Boxes 11a through 11d: Enter the name, address, telephone number, and email address of each person or entity that has discretionary authority, control or responsibility with respect to the administration of the MEWA or ECE, and any EIN used by such in reporting to the Department of Labor or the Internal Revenue Service. For this purpose, use only an EIN associated with the person or entity. Do not use any EIN associated with the MEWA or ECE itself.

Boxes 12a through 12d: Enter the names, address, and telephone number of the MEWAs or ECEs who were involved in a merger with the filing entity, any EIN used by such entity (or entities) in reporting to the Department of Labor or Internal Revenue Service, and any PN assigned to the plans or entities involved. If no merger has occurred, skip to Box 13.

Boxes 13 through 16c: Answer “yes” or “no” to the questions in this section. If your response requires additional explanation, identify the necessary information and attach pages as needed.

Box 13: With respect to Box 13, check “yes” or “no” as applicable. For this purpose, only check “yes” if the opinion is in writing and current within the last year. If you mark “yes,” you must also complete Boxes 8a through 8c. In addition, if Box 13 is marked “yes”, you must attach the actuarial report. See page 4 “Attaching Additional Pages” for instructions.

We note that the Department has the authority to issue an ex parte cease and desist order if it appears that a MEWA “creates an immediate danger to the public safety or welfare” which includes a MEWA that “fails to establish and implement a policy or method to determine that the MEWA is actuarially sound with appropriate reserves and adequate underwriting.”

Boxes 14a and 14b: With respect to Boxes 14a and 14b, check “yes” or “no” as applicable. If “yes,” provide the name of the issuer in the space provided.

Box 15: With respect to Box 15, check “yes” or “no” as applicable. If you answer “no,” include an explanation in the space provided or attach additional documents.

Boxes 16a through 16c: With respect to Boxes 16a through 16c, check “yes” or “no” as applicable.

If you check “yes” to Box 16a, you must identify each proceeding and attach pages as needed to include (1) the case number, (2) the case 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. For this purpose, include only audits and investigations that result in corrective action.

If you check “yes” to Box 16b, provide additional explanation as appropriate.

If you check “yes” to Box 16c, list the issuing entities and the year in which each order was issued.

Boxes 17a through 17j: Complete the chart with the information that is current as of the date of filing, except for an annual report, which must reflect the information that is current as of the last day of the previous calendar year or fiscal year. See “Annual Report” paragraph in Section 2. Complete a new row for each state in which the MEWA operates. When completing the chart, complete Box 17a first. Then for each row, complete Boxes 17b through 17j as it applies to the State listed in Box 17a.

Important: Using the drop down menu that appears on the screen when you are completing the Form, separately complete Boxes 17a-j for each State in which the MEWA operates.

Reminder: All MEWAs that provide medical care (within the meaning of ERISA section 733(a)(2)), including MEWAs that are not also “employee welfare benefit plans” must complete the chart.

Box 17a. Enter all States in which the MEWA or ECE provides benefits for medical coverage. For this purpose, list the State(s) where the employers (of the employees receiving coverage) are domiciled. State means State within the meaning of 29 CFR 2590.701–2. Indicate if a State was not included on previous M-1 filings by checking the “New State?” Box.

For example, consider MEWA A is located in State A and provides coverage to the employees of an Employer B located in State B. Employer B has employees located in State A, State B, and State C. In this example, MEWA A would report State B in Box 17a. However, State A and State C would not be listed because it is not a State where an Employer with employees receiving coverage from a MEWA is domiciled.

Box 17b: For each State listed in Box 17a, specify whether or not coverage is provided in that State.

Box 17c: For each State listed in Box 17a, specify the State registration number for the MEWA or ECE.

Box 17d: For each State listed in Box 17a, state the name of the agent or entity for service of process in that State.

Box 17e: For each State listed in Box 17a, respond “yes” or “no” to whether the entity is licensed or otherwise authorized to operate as a health insurance issuer in each State listed in that row. For more information on whether an entity that is a licensed or registered MEWA or ECE in a State meets the definition of a health insurance issuer in that State, contact the State Insurance Department.

Box 17f: For each “yes” answer in Box 17e, enter the National Association of Insurance Commissioners (NAIC) number.

Box 17g: For each “no” answer in Box 17e, specify whether the MEWA or ECE is fully insured through one or more health insurance issuers in each State.

Box 17h: For each “yes” answer in Box 17g, enter the name of the insurer and its NAIC number (if available). If there is more than one insurer, enter all insurers and their NAIC numbers (if available).

Box 17i: In each State listed in Box 17a, specify whether the MEWA or ECE has purchased any stop-loss coverage. For this purpose, stop-loss coverage includes any coverage defined by the State as stop-loss coverage.

Stop- loss coverage also includes any financial reimbursement instrument that is related to liability for the payment of health claims by the MEWA or ECE, including reinsurance and excess loss insurance.

Box 17j: For each “yes” answer in Box 17i, enter the name of the stop-loss insurer and its NAIC number (if available). If there is more than one stop-loss insurer, enter all stop-loss insurers and their NAIC numbers (if available).

Box 18: Of the States identified in Box 17a, identify all States in which the MEWA or ECE conducted 20

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percent or more of its business (based on the number of participants receiving coverage for medical care under the MEWA or ECE).

For example, consider a MEWA that offers or provides coverage to the employees of six employers. Two employers are located in State X and 70 participants in the MEWA receive coverage through these two employers. Three employers are located in State Y and 30 participants in the MEWA receive coverage through these three employers. Finally, one employer is located in State Z and 200 participants in the MEWA receive coverage through this employer. In this example, the administrator of the MEWA should specify State X and State Z under Box 18 because the MEWA conducts 23 1/3 percent of its business in State X (70/300 = 23 1/3

percent) and 66 2/3 percent of its business in State Z (200/300 = 66 2/3 percent). However, the administrator should not specify State Y because the MEWA conducts only 10 percent of its business in State Y (30/300 = 10 percent). Complete Box 18 with information that is current as of the date of filing, except for an annual report, which may reflect the information that is current as of the last day of the previous calendar year or fiscal year.

Box 19: Identify the total number of participants covered under the MEWA or ECE. For more information on determining the number of participants, see the Department of Labor’s regulations at 29 CFR 2510.3- 3(d).

The description of ‘‘participant’’ in the instructions below is only for purposes of this Box.

An individual becomes a participant covered under a MEWA or ECE on the earliest of:

• the date designated by the MEWA or ECE as the date on which the individual begins participation in the MEWA or ECE;

• the date on which the individual becomes eligible under the MEWA or ECE for a benefit subject only to occurrence of the contingency for which the benefit is provided; or

• the date on which the individual makes a contribution to the MEWA or ECE, whether voluntary or mandatory.

See 29 CFR 2510.3-3(d)(1). This includes former employees who are receiving group health continuation coverage benefits pursuant to Part 6 of ERISA and who are covered by the MEWA or ECE. Covered dependents are not counted as participants. A child who is an “alternate recipient” entitled to health benefits under a qualified medical child support order (QMCSO) should not be counted as a participant. An individual is not a participant covered under a MEWA or ECE on the earliest date on which the individual (a) is ineligible to receive any benefit under the MEWA or ECE even if the contingency for which such benefit is provided should occur, and (b) is not designated by the MEWA or ECE as a participant. See 29 CFR 2510.3- 3(d)(2).

If the report is a registration, origination, or special filing, complete this item with information that is current as of the date of the filing. Otherwise, complete this item with information that is current as of the last day of the year to be reported. (See Section 2 on Annual Report General Rule.)

Part III– Information for Compliance with Part 7 of ERISA

Background Information on Part 7 of ERISA:

The Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104–191) (HIPAA) amended ERISA to provide for, among other things, improved portability and continuity of health insurance coverage. The Mental Health Parity Act of 1996 (Pub. L. 104– 204, as amended by Pub. L. 107–116 and Pub. L.

107–147) (MHPA) amended ERISA to provide parity in the application of annual and lifetime dollar limits for certain mental health benefits with such dollar limits on medical and surgical benefits. The Paul Wellstone and Pete Domenici Mental Health Parity and

Addiction Equity Act of 2008 (Pub. L. 110-343) (MHPAEA) amended ERISA by expanding the MHPA rules to provide benefits for substance use disorders, as well as added new rules for parity in financial requirements and treatment limitations. The Newborns’ and Mothers’ Health Protection Act of 1996 (Pub. L. 104–204) (Newborns’ Act) amended ERISA to provide new protections for mothers and their newborn children with regard to the length of hospital stays in connection with childbirth. The Women’s Health and Cancer Rights Act of 1998 (Pub. L. 105–

277) (WHCRA) amended ERISA to provide individuals new rights for reconstructive surgery in connection with a mastectomy. The Genetic Information Nondiscrimination Act of 2008 (Pub. L. 110-233) (GINA) amended ERISA to prohibit the use of genetic information to adjust group premiums or contributions, prohibit the collection of genetic information, and prohibit requesting individuals to undergo genetic testing. Michelle’s Law (Pub. L. 110-

381. amended ERISA to prohibit group health plans and issuers from terminating coverage for a dependent child, whose enrollment in the plan requires student status at a postsecondary educational institution, if the student status is lost as a result of a medically necessary leave of absence. The Patient Protection and Affordable Care Act (Pub. L. 111-148) (the Affordable Care Act) amended ERISA to provide a wide range of protections for participants of group health plans. All of the foregoing provisions are set forth in part 7 of subtitle B of title I of ERISA (part 7).

The Department of Labor has published informal guidance in its publication, Health Benefits Coverage Under Federal Law. This publication provides assistance

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in understanding the HIPAA portability, HIPAA nondiscrimination, CHIPRA, GINA, WHCRA, and Newborns’ Act requirements.

Information on the Affordable Care Act is available on EBSA’s website at https://www.dol.gov/agencies/ebsa/laws-and- regulations/laws/affordable-care-act/for-employers- and-advisers. Additionally, the website will be updated when any new information or guidance relevant to part 7 of ERISA is made available. A Self-Compliance Tool, which may be used to help assess an entity’s compliance with part 7 of ERISA, is available at www.dol.gov/sites/default/files/ebsa/about-ebsa/our- activities/resource-center/publications/compliance- assistance-guide-appendix-a.pdf. This tool provides information guidance with respect to all the provisions listed above.

General Information Regarding the Applicability of Part 7: In general, the foregoing provisions apply to group health plans and health insurance issuers in connection with a group health plan.

Many MEWAs and ECEs are group health plans or health insurance issuers. However, even if a MEWA or ECE is neither a group health plan nor a health insurance issuer, if the MEWA or ECE offers or provides benefits for medical care through one or more group health plans, the coverage is required to comply with part 7 of ERISA and the MEWA or ECE is required to complete Boxes 20 through 21f.

Part 7 of ERISA does not apply to any group health plan or group health insurance issuer in relation to its provision of excepted benefits. Certain benefits that are generally not health coverage are excepted in all circumstances.

These benefits are: coverage only for accidents (including accidental death and dismemberment), disability income insurance, liability insurance (including general liability insurance and automobile liability insurance), coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, automobile medical payment insurance, credit-only insurance (for example, mortgage insurance), and coverage for on-site medical clinics.

Other benefits that generally are health coverage are excepted if certain conditions are met. Specifically, limited scope dental benefits, limited scope vision benefits, and long-term care benefits are excepted if they are provided under a separate policy, certificate, or contract of insurance, or are otherwise not an integral part of the group health plan. Benefits provided under a health flexible spending arrangement may also qualify as excepted benefits if certain requirements are met.

For more information on limited excepted benefits, see the Department of Labor’s regulations at 29 CFR 2590.732(c)(3).

In addition, noncoordinated benefits may be excepted benefits. The term “noncoordinated benefits” refers to coverage for a specified disease or illness (such as cancer-only coverage) or hospital indemnity or other

fixed dollar indemnity insurance (such as insurance that pays $100/day for a hospital stay as its only insurance benefit), if three conditions are met. First, the benefits must be provided under a separate policy, certificate, or contract of insurance. Second, there can be no coordination between the provision of these benefits and an exclusion of benefits under a group health plan maintained by the same plan sponsor. Third, benefits must be paid without regard to whether benefits are provided with respect to the same event under a group health plan maintained by the same plan sponsor. For more information on these noncoordinated excepted benefits, see the Department of Labor’s regulations at 29 CFR 2590.732(c)(4).

Finally, supplemental benefits may be excepted if certain conditions are met. Specifically, the benefits are excepted only if they are provided under a separate policy, certificate or contract of insurance, and the benefits are Medicare supplemental (commonly known as “Medigap” or “MedSupp”) policies, TRICARE supplements, or supplements to certain employer group health plans.

Such supplemental coverage cannot duplicate primary coverage and must be specifically designed to fill gaps in primary coverage, coinsurance, or deductibles. For more information on supplemental excepted benefits, see the Department of Labor’s Field Assistance Bulletin 2007-04.

Note that retiree coverage under a group health plan that coordinates with Medicare may serve a supplemental function similar to that of a Medigap policy. However, such employer-provided retiree “wrap around” benefits are not excepted benefits (because they are expressly excluded from the definition of a Medicare supplemental policy in section 1882(g)(1) of the Social Security Act).

For more information on supplemental excepted benefits, see the Department of Labor’s regulations at 29 CFR 2590.732(c)(5).

Relation to Other Laws: States may, under certain circumstances, impose stricter laws with respect to health insurance issuers. Generally, questions concerning State laws should be directed to that State’s Insurance Department.

For More Information: Guidance material and additional compliance assistance information that may be helpful in understanding the requirements listed above is available in publications, fact sheets, and frequently asked questions available on EBSA’s website at www.dol.gov/agencies/ebsa.

Interested persons may also call and speak to a benefits advisor about these laws using the EBSA toll- free hotline at 1-866-444-3272.

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Box 20: With respect to Box 20, check “yes” or “no” as applicable. Check “yes” if you answered “yes” in Box 16a and such litigation or enforcement proceeding was related to a provision under part 7 of ERISA.

Box 21: MEWAs or ECEs that are subject to part 7 of ERISA on the date of the filing must indicate their compliance with the provisions of part 7 of ERISA.

In general, if you are the administrator of a MEWA that provides benefits consisting of medical care (within the meaning of ERISA section 733(a)(2)) or an ECE that is a group health plan or health insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans, you must answer “yes” to Box 21 and then proceed to Boxes 21a-21f. For purposes of determining if a MEWA or ECE is in compliance with these provisions, the administrator should check the relevant statutory provisions implementing regulations. In addition, the Self- Compliance Tool at https://www.dol.gov/agencies/ebsa/employers- and-advisers/plan-administration-and- compliance/health-plans/hbec/checksheets may be helpful in answering Boxes 21a through 21f.

Note: For MEWAs or ECEs who that are not yet providing benefits and so are unable to evaluate their compliance with part 7 as of the date the Form M-1 is filed, check “no” and proceed to the signature. Such MEWAs and ECEs, however, are generally required to indicate part 7 compliance on their next required annual filing.

Box 21a: The HIPAA portability requirements added sections 701, 702, and 703 of ERISA. Title I of GINA amended section 702 of ERISA.

General Applicability. In general, you must answer “yes” or “no” to this question if you are the administrator of a MEWA or ECE that is a group health plan or health

insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans.

Exceptions. You may answer “N/A” if either of the following paragraphs apply:

1. The MEWA or ECE is a small health plan (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations)

2. The MEWA or ECE offers coverage only to small group health plans (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

Box 21b: MHPA added section 712 of ERISA. MHPAEA amended section 712 of ERISA.

General Applicability. In general, you must answer “yes” or “no” to this question if you are the administrator of a MEWA or ECE that is a group health plan or health insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans.

Exceptions. You may answer “N/A” if any of the following paragraphs apply:

1. The MEWA or ECE is a small group health plan (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

2. The MEWA or ECE offers coverage only to small group health plans (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

3. The MEWA or ECE does not provide both medical/ surgical benefits and mental health benefits.

4. The MEWA or ECE offers or provides coverage only to small employers (as described in the small employer exemption contained in section 712(c)(1) of ERISA and §2590.712(e) of the Department’s regulations).

5. The coverage has satisfied the requirements for the increased cost exemption (described in section 712(c) of ERISA and §2590.712(f) of the Department’s regulations).

Box 21c: The Newborns’ Act added section 711 of ERISA.

General Applicability. In general, you must answer “yes” or “no” to this question if you are the administrator of a MEWA or ECE that is a group health plan or health insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans.

Exceptions. You may answer “N/A” if either of the following paragraphs apply:

1. The MEWA or ECE does not provide benefits for hospital lengths of stay in connection with childbirth.

2. The MEWA or ECE is subject to State law regulating such coverage, instead of the Federal Newborns’ Act requirements, in all States identified in Box 17a, in accordance with section 711(f) of ERISA and §2590.711(e) of the Department’s regulations.

Box 21d: WHCRA added section 713 of ERISA.

General Applicability. In general, you must answer “yes” or “no” to this question if you are the administrator of a MEWA or ECE that is a group health plan or health insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans.

Exceptions. You may answer “N/A” if any of the following paragraphs apply:

1. The MEWA or ECE is a small health plan (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

2. The MEWA or ECE offers coverage only to small group health plans (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

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3. The MEWA or ECE does not provide medical/ surgical benefits with respect to a mastectomy.

Box 21e: Michelle’s Law added section 714 of ERISA.

General Applicability. In general, you must answer “yes” or “no” to this question if you are the administrator of a MEWA or ECE that is a group health plan or health insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans.

Exceptions. You may answer “N/A” if any of the following paragraphs apply:

1. The MEWA or ECE is a small health plan (as described in section 732(a) of ERISA and

§2590.732(b) of the Department’s regulations).

2. The MEWA or ECE offers coverage only to small group health plans (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

3. The MEWA or ECE does not provide coverage to dependents.

Box 21f: The Affordable Care Act amends section 715 of ERISA to incorporate, by reference, changes to the PHS Act.

General Applicability. In general, you must answer “yes” or “no” to this question if you are the administrator of a MEWA or ECE that is a group health plan or health

insurance issuer or a MEWA or ECE that provides benefits for medical care to employees through one or more group health plans.

Exceptions. You may answer “N/A” if any of the following paragraphs apply:

1. The MEWA or ECE is a small health plan (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

2. The MEWA or ECE offers coverage only to small group health plans (as described in section 732(a) of ERISA and §2590.732(b) of the Department’s regulations).

Paperwork Reduction Act Notice

We ask for the information on this form to carry out the law as specified in ERISA. You are required to give us the information. We need it to determine whether the MEWA is operating according to law. You are not required to respond to this collection of information unless it displays a current, valid OMB control number. The average time needed to complete and file the form is estimated below. These times will vary depending on individual circumstances.

Learning about the law or the form: 2 hrs.

Preparing the form: 1 hr. and 20 min. - 2 hrs. and 35 min.

Please send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Official, 200 Constitution Avenue, N.W., Room N-5711, Washington, DC 20210 and reference OMB Control Number 1210-0116.

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