Receipt Confirmation Code: 00009680-1035

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.

OMB No. 1210-0116

Department of Labor
Employee Benefits Security Administration

PART I
PURPOSE OF FILING

Complete as applicable:

A
(1) Annual Report:
  • Calendar Year
  • or the fiscal year beginning and ending
(2) MEWA Registration
(3) ECE Origination
(4) ECE Special Filing
B
Check here if this is a final report
Check here if this is an amended report
Check here if this is a Request for an extension
C
Identify the type of entity:
(1) A Plan MEWA
(2) A Non-Plan MEWA
(3) An Entity Claiming Exception (ECE)
D
Enter the most recent date the MEWA or ECE filed the Form M-1:
Check the box if this is the first filing or enter the date below: 11/19/2018

PART II
CUSTODIAL & FINANCIAL INFORMATION

1a
Name and address of the MEWA or ECE
HR Outsourcing Associates, LLC

8215 FOREST POINT BLVD
SUITE 150
CHAROLOTTE, NC 28273
1b
Telephone number of the MEWA or ECE (770) 349-8880
1c
Employer Identification Number (EIN) 27-0490674
1d
Plan Number (PN) 501
2a
Name and address of the administrator of the MEWA or ECE
HR Outsourcing Associates, LLC
SARAH SMITH
8215 FOREST POINT BLVD
SUITE 150
CHAROLOTTE, NC 28273
2b
Telephone number of the administrator (770) 349-8880
2c
EIN 27-0490674
2d
E-mail address of the administrator
SARAH.SMITH@HROI.COM
3a
Name and address of the entity or entities sponsoring the MEWA or ECE
HR Outsourcing Associates, LLC

8215 FOREST POINT BLVD
SUITE 150
CHAROLOTTE, NC 28273
3b
Telephone number of the sponsor (770) 349-8880
3c
EIN 27-0490674
4a
Name and address of the agent for service of process or registered agent
STEPHANIE L SCHAEFFER, CHIEF LEGAL OFFICER
PAYCHEX INC
911 PANORAMA TRAIL SOUTH

ROCHESTER, NY 14625
4b
Telephone number of such person (585) 383-3788
4c
E-mail address of such person
SLSCHAEFFER@PAYCHEX.COM
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
EFRAIN RIVERA, CFO/DIRECTOR
HR Outsourcing Associates, LLC
911 PANORAMA TRAIL SOUTH

ROCHESTER, NY 14625
5b
Telephone number of each such person (585) 387-6501
5c
E-mail address of such person
ERIVERA@PAYCHEX.COM
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
STEPHANIE L SCHAEFFER, SECRETARY
HR Outsourcing Associates, LLC
911 PANORAMA TRAIL SOUTH

ROCHESTER, NY 14625
5b
Telephone number of each such person (585) 383-3788
5c
E-mail address of such person
SLSCHAEFFER@PAYCHEX.COM
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
JOHN B GIBSON, PRESIDENT
HR Outsourcing Associates, LLC
911 PANORAMA TRAIL SOUTH

ROCHESTER, NY 14625
5b
Telephone number of each such person (585) 383-3402
5c
E-mail address of such person
JBGIBSON1@PAYCHEX.COM
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
LAURIE A MAFFETT, VICE PRESIDENT
HR Outsourcing Associates, LLC
1175 JOHN STREET

WEST HENRIETTA, NY 14586
5b
Telephone number of each such person (585) 336-7301
5c
E-mail address of such person
LMAFFETT@PAYCHEX.COM
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 promotor or agent
7a
Name and address of any person, financial institution(s), or other entity holding assets for the MEWA or ECE
HR OUTSOURCING HOLDINGS INC WELFARE BENEFITS PLAN

8215 FOREST POINT BLVD
SUITE 150
CHARLOTTE, NC 28273
7b
Telephone Number of person, financial institution, or entity (770) 349-8880
8a
Name and address of any actuary(ies) providing services to the MEWA or ECE
Wakely Consulting Group, LLC

8000 South Chester Street
Suite 650
Centennial, CO 80112
8b
Telephone number of each actuary (720) 226-9800
8c
E-mail address of each actuary
jamie.moorhead@wakely.com
8d
EIN of each actuary 47-4522915
9a
If the MEWA or ECE has a contract with a third party administrator (TPA) the name and address of the third party administrator(s)
UMR, INC

PO BOX 9472

MINNEAPOLIS, MN 55440-9472
9b
Telephone number of each TPA (513) 619-3624
9c
E-mail address of each TPA
rbrandenburg@umr.com
9d
EIN of each TPA 39-1995276
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
HR OUTSOURCING HOLDINGS INC WELFARE BENEFITS PLAN

8215 FOREST POINT BLVD
SUITE 150
CHARLOTTE, NC 28273
10b
Telephone number of each such person or entity (770) 349-8880
10c
E-mail address of such person or entity
SARAH.SMITH@HROI.COM
10d
EIN of each such person or entity 30-0986199
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
Aetna, Inc.

4630 Woodland Corporate Boulevard

Tampa, FL 33614
11b
Telephone number of each such person or entity (813) 447-1872
11c
E-mail address of such person or entity
MangiaficoM@aetna.com
11d
EIN of each such person or entity 23-2229683
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
Davis Vision Inc.

450 - 106 State Road 13 N. #403

St. Johns, FL 32259
11b
Telephone number of each such person or entity (800) 731-4201
11c
E-mail address of such person or entity
cproffitt@davisvision.com
11d
EIN of each such person or entity 11-3051991
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
Blue Cross Blue Shield of Florida, Inc.

4800 Deerwood Campus Pkwy
Deerwood Park North – DCC 3-5
Jacksonville, FL 32246
11b
Telephone number of each such person or entity (904) 905-8034
11c
E-mail address of such person or entity
Greg.Ferguson@floridablue.com
11d
EIN of each such person or entity 59-2015694
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
The Guardian Life Insurance Company

1511 N. West Shore Blvd.
Suite 600
Tampa, FL 33607-4594
11b
Telephone number of each such person or entity (813) 472-6124
11c
E-mail address of such person or entity
Eddie_Aspiro@glic.com
11d
EIN of each such person or entity 13-5123390
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
Kaiser Foundation Health Plan Inc

3100 Thornton Ave, 3rd Floor

Burbank, CA 91504
11b
Telephone number of each such person or entity (818) 525-4331
11c
E-mail address of such person or entity
Michael.A.Kin@kp.org
11d
EIN of each such person or entity 94-1340523
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
Lincoln National Life Insurance Company

1600 Riveredge Pkwy
Suite 130
Atlanta, GA 30328
11b
Telephone number of each such person or entity (770) 799-7913
11c
E-mail address of such person or entity
wendi.gross@lfg.com
11d
EIN of each such person or entity 35-0472300
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
UMR, INC

PO BOX 9472

MINNEAPOLIS, MN 55440-9472
11b
Telephone number of each such person or entity (513) 619-3624
11c
E-mail address of such person or entity
rbrandenburg@umr.com
11d
EIN of each such person or entity 39-1995276
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
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, A CHUBB 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
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 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
Entity Year
17
Complete the following chart:
17a 17b 17c 17d 17e 17f 17g 17h 17i 17j
Enter all States where the MEWA or ECE is operating. 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.
AZ
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES INC 815 N 1ST AVE STE 4, PHEONIX, AZ 85003 No N/A Yes AETNA HEALTH INC - 95094 No N/A
CA
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC455 CAPITOL MALL COMPLEX STE 217 SACRAMENTO CA 95814 No N/A Yes AETNA HEALTH INC - 95094 and KAISER - 0000 No N/A
CT
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC 330 ROBERTS STREET, SUTIE 203, HARTFORD, CT, 06108-3654 No N/A Yes AETNA HEALTH INC - 95094 No N/A
DE
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC 1675 S STATE ST STE B DOVER DE 19901 No N/A Yes Blue Cross Blue Shield of Florida, Inc. - 98167 Yes Blue Cross Blue Shield of Florida, Inc. - 98167
FL
Is new? 		Yes N/A C T Corportion System 1200 South Pine Island Road, Ste 250 Plantation, FL3324 No N/A Yes Blue Cross Blue Shield of Florida, Inc. - 98167 and AETNA HEALTH INC - 95094 Yes Blue Cross Blue Shield of Florida, Inc. - 98167
GA
Is new? 		Yes N/A Steve Zeigler, 1588 ATKINSON ROAD, LAWRENCEVILLE, GA, 30043 No N/A Yes Blue Cross Blue Shield of Florida, Inc. - 98167 and AETNA HEALTH INC - 95094 Yes Blue Cross Blue Shield of Florida, Inc. - 98167
KY
Is new? 		Yes N/A CORPORATION SERVICE COMPANY INC 828 LANE ALLEN RD, STE 219, LEXINGTON, KY 40504 No N/A Yes AETNA HEALTH INC - 95094 No N/A
MO
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC 222 E. DUNKLIN, STE 102, JEFFERSON CITY, MO 65101 No N/A No Blue Cross Blue Shield of Florida, Inc. - 98167 and AETNA HEALTH INC - 95094 Yes Blue Cross Blue Shield of Florida, Inc. - 98167 AND SUN LIFE ASSURANCE COMPANY OF CANADA - 80802
NC
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC, 13860 BALLANTYNE CORPORATE PLACE STE 410, CHARLOTTE, NC 28277 No N/A Yes AETNA HEALTH INC - 95094 No N/A
NJ
Is new? 		Yes N/A The Corporate Trust Company 820 Bear Tavern Road #105 West Trenton, NJ 08628 No N/A Yes AETNA HEALTH INC - 95094 No N/A
NY
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC 1218 CENTRAL AVE, STE 100, ALBANY, NEW YORK, 12205 No N/A Yes Blue Cross Blue Shield of Florida, Inc. - 98167 and AETNA HEALTH INC - 95094 and KAISER - 0000 Yes Blue Cross Blue Shield of Florida, Inc. - 98167
SC
Is new? 		Yes N/A C T Corporation System, 2 OFFICE PARK CT. STE. 103, COLUMBIA, SOUTH CAROLINA 29223 No N/A Yes AETNA HEALTH INC - 95094 No N/A
TN
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC 992 DAVIDSON DR, STE B, NASHVILLE, TN 37205-1051 No N/A Yes AETNA HEALTH INC - 95094 No N/A
TX
Is new? 		Yes N/A CAPITOL CORPORATE SERVICES, INC 206 E. 9TH STREET, SUITE 1300 AUSTIN, TX 78701 No N/A No AETNA HEALTH INC - 95094 Yes SUN LIFE ASSURANCE COMPANY OF CANADA - 80802
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). FL
19
Total number of participants covered under the entity. 12200

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 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
21
Is the MEWA subject to part 7 of ERISA on the date of the filing? (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

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.