Form M-1 - Report For Multiple Employer Welfare Arrangements (Mewas) And Certain Entities Claiming Exception (Eces) - Department Of Labor 2012 Page 3
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3Form M-1
Page 3
17
Complete the following chart:
17a
17b
17c
17d
17e
17f
17g
17h
17i
17j
Enter all
Is coverage
State
Name of
Is the entity
If yes to
If no to
If yes to
Does the
If yes to
States
provided?
registration
state agent
a licensed
17e, enter
17e, is the
17g, enter
entity
17i, enter
where the
number.
or entity for
health
NAIC
entity fully
name
purchase
the name
MEWA
service of
insurer in
number.
insured?
and NAIC
stop loss
and NAIC
or ECE is
process.
this State?
number of
coverage?
number of
operating.
insurer.
insurer.
18
Of the States identified in box 17a, identify those States in which the entity conducted 20 percent or more of its business (based
on the number of participants receiving coverage for medical care).
19
Total number of participants covered under the entity. .................................................................................
PART III
INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA
20
If you answered yes to box 16a, in reference to any State or Federal litigation or enforcement proceeding
(including any administrative proceeding), check yes below if the allegation concerns a provision under
part 7 of ERISA, a corresponding provision under the Internal Revenue Code or Public Health Service Act,
a breach of any duty under Title I of ERISA if the underlying violation relates to a requirement under part 7
of ERISA, or a breach of a contractual obligation if the contract provision relates to a requirement under
part 7 of ERISA. ...........................................................................................................................................
Yes
No
21
Is this a filing for which compliance with part 7 can be evaluated?
(Note: The Self-Compliance Tool at may be
helpful in answering Boxes 21a-21f.) If “yes,” complete the following. ..........................................................
Yes
No
21a Is the coverage provided by the MEWA or ECE in compliance with the portability and
nondiscrimination provisions of the Health Insurance Portability and Accountability Act of 1996,
including Title I of the Genetic Information Nondiscrimination Act of 2008, and the Department of
Labor’s (Department’s) regulations issued thereunder? ...................................................................
Yes
No
N/A
21b Is the coverage provided by the MEWA or ECE in compliance with the Mental Health Parity Act
of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 and the Department’s
regulations issued thereunder? ........................................................................................................
Yes
No
N/A
21c Is the coverage provided by the MEWA or ECE in compliance with the Newborns’ and Mothers’
Health Protection Act of 1996 and the Department’s regulations issued thereunder? .....................
Yes
No
N/A
21d Is the coverage provided by the MEWA or ECE in compliance with the Women’s Health and
Cancer Rights Act of 1998? ..............................................................................................................
Yes
No
N/A
21e Is the coverage provided by the MEWA or ECE in compliance with Michelle’s Law? .......................
Yes
No
N/A
21f Is the coverage provided by the MEWA or ECE in compliance with the Patient Protection and
Affordable Care Act of 2010 and the Department’s regulations issued thereunder that are
applicable as of the date signed at the bottom of this form? ............................................................
Yes
No
N/A
ATTACHMENTS
SIGNATURE
Under penalty of perjury and other penalties set forth in the instructions, I declare that I have examined this report, including any
accompanying attachments, and to the best of my knowledge and belief, it is true and correct. Under penalty of perjury and other
penalties set forth in the instructions, I also declare that, unless this is an extension request, this report is complete.
Signature of Administrator:
Address of Administrator:
Date:
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