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.
For inquiries regarding electronic filing capability, contact the EBSA computer help desk at
202-693-8600.

(2)
(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.
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/affordablecare-act/for- employers-and-advisers
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-andinitiatives/outreach-and-education/hbec.

(2)

(3)

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/resourcecenter/publications, by contacting EBSA electronically at www.dol.gov/agencies/ebsa/aboutebsa/ask-a-question/ask-ebsa or by calling toll-free 1-866-444-3272.

2018
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.

PART I

1a

2a

3a

4a

5a

6a

Department of Labor
Employee Benefits
Security Administration

PURPOSE OF FILING

Complete as applicable:
A Identify the type of filing:
(1) Annual Report:
 Calendar Year; or
 Fiscal Year beginning
and ending
(2) Registration Enter Date: _________________________
(3) Origination Enter Date: _________________________
(4) Special Filing Enter Date: ________________________
B (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 

PART II

OMB No. 1210-0116

C Identify the type of entity:
(1) A Plan MEWA
(2)  A Non-Plan MEWA
(3)  An Entity Claiming Exception
D 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.

CUSTODIAL & FINANCIAL INFORMATION

Name and address of the MEWA or ECE

Name and address of the administrator of the MEWA or ECE

Name and address of the entity or entities sponsoring the MEWA or ECE

Name and address of the agent for service of process or registered agent

Name and address of each member of the Board, officer, trustee, or
custodian of the MEWA or ECE

Name and address of all promoters and/or agents responsible for
marketing the MEWA or ECE

1b

Telephone number of the MEWA or ECE

1c

Employer Identification Number (EIN)

1d

Plan Number (PN)

2b

Telephone number of the administrator

2c

EIN

2d

E-mail address of the administrator

3b

Telephone number of the sponsor

3c

EIN

4b

Telephone number of such person

4c

E-mail address of such person

5b

Telephone number of each such person

5c

E-mail address of such person

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

9b

Telephone number of each TPA

9c

E-mail address of each TPA

9d

EIN of each TPA

9a

If the MEWA or ECE has a contract with a third party administrator
(TPA), the name and address of the TPA(s)

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

14a Are your entity, and/or its officers, directors, and employees covered by fiduciary liability policies? Please identify the carrier that
 Yes  No
issued the fiduciary liability policy(ies) in the space provided.
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
 Yes  No If yes, please explain.
involving dishonesty or breach of trust or been convicted of a felony?
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.)
17b
17c
17d
17e
17f
17g
17h
17i
17j
17a
Is coverage State
Name of
Is the entity If yes to
If no to
If yes to
Does the
If yes to
Enter
provided?
registration state agent a licensed 17e, enter 17e, is the 17g, enter entity
17i, enter
State
number.
or entity for health
NAIC
entity fully
name
purchase
the name
where the
number.
and NAIC stop loss
service of
insurer in
insured?
and NAIC
MEWA
number of coverage? number of
process.
this State?
or ECE is
insurer.
insurer.
operating.

18
19

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).
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
20

21

INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA

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

Is the MEWA subject to part 7 of ERISA on the date of the filing?
(Note: The Self-Compliance Tool at https://www.dol.gov/agencies/ebsa/employers-and-advisers/planadministration-and-compliance/health-plans/hbec/checksheets.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 thereunder? ..............................................................................

 Yes

No

 N/A

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 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

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

21b

21d

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 1031.
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 $1,558
a day. The penalty is applicable only to civil penalties
assessed after January 2, 2018, 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.

SECTION 1: Who Must File
General Rules
A MEWA that is required to file an M-1 is an employee
welfare benefit plan or other arrangement that provides
benefits consisting of medical care (within the meaning
of ERISA section 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.)

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 ................................................... 4
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............................................. 9
Paperwork Reduction Act Notice ............................. 12

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.
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 multipleemployer 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 2520.10443, those plans participating in a GIA are exempt from
the requirement to file a Form5500. See Form 5500
instructions.
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

Page 2

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 2590.1012(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).
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, 2019, calendar year 2018 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,
2019, fiscal year 2019 information may be used if the
administrator has at least 6 continuous months of fiscal
year 2018 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, 2019 would use the 2018 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 M1 that is available to do so. (For example, an
origination filing due by November 1, 2019 would
use the 2018 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
Page 3

(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, 2019 would use the 2018
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 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
Page 4

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.
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, and, indicate the date of the
registration, origination, or occurrence of the reason
requiring a special filing.
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 1-866-4633278.
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: For those entities and individuals that are
required to be reported in Boxes 1a-11a and also on
the Form 5500 (including its Schedules and
Attachments) use the same name, EIN, and other
identifying information.
Page 5

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 in
reporting 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 1-800-8294933 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. or call toll-free at 1-866-4633278.) 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 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.
Page 6

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 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.
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.
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.
Page 7

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 stoploss coverage. For this purpose, stop-loss coverage
includes any coverage defined by the State as stoploss 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
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.)

Page 8

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. 1
10-343) (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. 110381) 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 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-andregulations/laws/affordable-care-act/for-employersand-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/aboutebsa/our- activities/resourcecenter/publications/compliance-assistance-guideappendix-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
Page 9

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.
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 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/employersand-advisers/plan-administration-andcompliance/health-plans/hbec/checksheets may
be helpful in answering Boxes 21a through 21f.
Note: For MEWAs or ECEs 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 the
Department’s regulations).

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(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:

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).

(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 medical/
surgical benefits with respect to a mastectomy.

Page 11

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 N5711, Washington, DC 20210 and reference OMB
Control Number 1210-0116.

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