Receipt Confirmation Code: 00005500-1983

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:

PART II
CUSTODIAL & FINANCIAL INFORMATION

Name and address of the MEWA or ECE


                Land O'Lakes, Inc. Member Cooperative Health Plan

                

                PO Box 64101

                MS4098

                St. Paul,  MN  55164

Telephone number of the MEWA or ECE (651) 481-2222

Employer Identification Number (EIN) 46-2631103

Plan Number (PN) 601

Name and address of the administrator of the MEWA or ECE


                Governing Board of the Land O'Lakes, Inc. Member Cooperative Health Plan

                Attn:  Pamela Grove

                PO Box 64101

                MS4098

                St. Paul,  MN  55164

Telephone number of the administrator (651) 375-2167

EIN

E-mail address of the administrator
pjgrove@landolakes.com

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


                Land O'Lakes, Inc.

                

                PO Box 64101

                

                St. Paul,  MN  55164

Telephone number of the sponsor

EIN 41-0365145

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


                Land O'Lakes, Inc.

                Attn:  Pamela Grove

                PO Box 64101

                MS4098

                St. Paul,  MN  55164

Telephone number of such person (651) 481-2222

E-mail address of such person
pjgrove@landolakes.com

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


                see attachment

Telephone number of each such person

E-mail address of such person
see attachment

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

n/a

Telephone number of each promoter or agent

E-mail address of such person

EIN of each promotor or agent

Name and address of any person, financial institution(s), or other entity holding assets for the MEWA or ECE

n/a

Telephone Number of person, financial institution, or entity

Name and address of any actuary(ies) providing services to the MEWA or ECE

n/a

Telephone number of each actuary

E-mail address of each actuary

EIN of each actuary

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


                Milliman, Inc.

                Attn: Jessica Butterworth

                1301 Fifth Avenue

                Suite 3800

                Seattle,  WA  98101

Telephone number of each TPA (206) 504-5714

E-mail address of each TPA
jessica.butterworth@milliman.com

EIN of each TPA 91-0675641

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

n/a

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


                Governing Board of the Land O'Lakes, Inc. Member Cooperative Health Plan

                Attn:  Pamela Grove

                PO Box 64101

                MS4098

                St. Paul,  MN  55164

11b

Telephone number of each such person or entity (651) 375-2167

11c

E-mail address of such person or entity
pjgrove@landolakes.com

11d

EIN of each such person or entity

12a

Names and addresses of the MEWAs or ECEs that merged

n/a

12b

Telephone number of the entities

12c

EINs

12d

PNs

Do you have an opinion from an actuary assessing the MEWA's or ECE's actuarial soundness, including the adequacy of contribution rates? No

14a

Are you, your entity, and/or its officers, directors, and employees covered by fiduciary liability policies? Please identify the carrier that issued the fiduciary liability policy(ies) in the space provided. Yes Federal Insurance Company

14b

Are the fiduciaries of each of the plans whose participants are receiving benefits from the entity covered by a fiduciary liability policy? Yes

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 If no, please explain.

16a

Within the past five years, has any litigation or other enforcement proceeding (including any administrative proceeding) regarding any MEWA, ECE, or Group Health Plan been instituted by a Federal or State agency against the MEWA or ECE, a trustee, or a director, owner, partner, senior manager, or officer of the sponsoring entity? No 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.

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? No If yes, please explain.

16c

Have any cease and desist orders been issued by a Federal or State agency against any of the entities listed in this Part II? No If so, please list the issuing entities and the year in which each order was issued.

Entity	Year

Complete the following chart:

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.
TN Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
TX Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
UT Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
VA Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
WA Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
WI Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
WY Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
AK Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
AL Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
AR Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
CA Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
CO Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
DE Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
IA Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
ID Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
IL Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
IN Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
KS Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
KY Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
LA Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
MI Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
MN Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
MO Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
MS Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
MT Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
ND Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
NE Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
OH Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
OK Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
OR Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
PA Is new?	No			No		Yes	Blue Cross and Blue Shield of MN, 55206	No
SD Is new?	Yes			No		Yes	Blue Cross and Blue Shield of MN, 55206	No

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). WI,MN

Total number of participants covered under the entity. 5183

PART III
INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA

If you answered yes to box 16a, in reference to any State or Federal litigation or other 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. N/A

Is this a filing for which compliance with part 7 can be evaluated? (Note: The Self-Compliance Tool at <a href="http://www.dol.gov/ebsa/pdf/cagappa.pdf">www.dol.gov/ebsa/pdf/cagappa.pdf</a> may be helpful in answering Boxes 21-21f.) If "yes," complete the following. Yes

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

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

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

21d

Is the coverage provided by the MEWA or ECE in compliance with the Women's Health and Cancer Rights Act of 1998? Yes

21e

Is the coverage provided by the MEWA or ECE in compliance with Michelle's Law? Yes

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

ATTACHMENTS

Governing Board Members of the Land O'Lakes, Inc. Member Cooperative Health Plan.docx

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:

2017 Form M-1

PART I PURPOSE OF FILING

PART II CUSTODIAL & FINANCIAL INFORMATION

PART III INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA

ATTACHMENTS

SIGNATURE

PART I
PURPOSE OF FILING

PART II
CUSTODIAL & FINANCIAL INFORMATION

PART III
INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA