Upload
anonymous-kprzciz
View
223
Download
0
Embed Size (px)
Citation preview
7/27/2019 Superior Officers Council - Redacted Bates HW
1/26
//C|/...Health%20and%20Welfare%20Fund/WAIVER--Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund.htm[08/04/2011 4:00:0
rom: Gogna, Anubhav ([email protected]) [[email protected]]ent: Tuesday, November 30, 2010 12:22 PM
To: HHS HealthInsurance (HHS)Cc: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected]); Killion, Tammy ([email protected]: WAIVER--Superior Officers Council Health and Welfare Fund
Attachments: Superior Officers Council Welfare Fund Actuary Certification.pdf; Superior Officers Council Welfaund Waiver--FINAL (11-30-10)..pdf
ear Mr. Mayhew,
n behalf of the Superior Officers Council Health and Welfare Fund ( the "Fund"), I am submitting this application for waiver of estricted annual limit under Public Health Services Act 2711, pursuant to OCIIO gulatory Guidance OCIIO 2010-1 an010-1A. The Fund has a per-family annual limit on prescription drug benefits of $ and, as detailed in the attached wapplication and accompanying actuarial projection, imposition of a $750,000 annual ould result in the Fund's insolvency, rastically reduced access to benefits for those currently covered by the Fund.
We appreciate your consideration of the Fund's request. Please let Lou Mazawey, Mark Nielsen or me know if you have anyuestions or need anything else. Lou can be reached at 202.861.6608, Mark can be reached at at 202.861.5429 and I can beeached at 202.861.2602.
est regards,
nubhav Gogna
019470/07]
Anubhav Gogna / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-2602 /Fax: 202-659-4503
www.Groom.com/[email protected]
otice: This message is intended only for use by the person or entity to which it is addressed. Because it may contain confidenformation intended solely for the addressee, you are notified that any disclosing, copying, downloading, distributing, or retainin
his message, and any attached files, is prohibited and may be a violation of state or federal law. If you received this message rror, please notify the sender by reply mail, and delete the message and all attached files.
o comply with U.S. Treasury Regulations, we also inform you that, unless expressly stated otherwise, any tax advice containehis communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenode, and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres this communication.
SupOff:000001
Document obtained by CompleteColorado.com
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/7/27/2019 Superior Officers Council - Redacted Bates HW
2/26
SupOff:000002
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
3/26
SupOff:000003
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
4/26
SupOff:000004
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
5/26
Pages 5 through 7 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4
SupOff:000005
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
6/26
//C|/...20from%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Correspondence%2012.13.10.htm[08/04/2011 4:00
rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 13, 2010 1:42 PM
To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)
am Lynne Moultrie
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services301) 492-4174
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 13, 2010 1:41 PMo: 'Gogna, Anubhav ([email protected])'c: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected])ubject: RE: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)
hank you for your information. Your application is now complete and you receive a determination of yourpplication within 30 days.
hank you.
am Lynne Moultrie
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
301) 492-4174
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
rom: Gogna, Anubhav ([email protected]) [mailto:[email protected]]ent: Thursday, December 09, 2010 9:53 AMo: Moultrie, Cam (HHS/OCIIO)c: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected])ubject: RE: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)
ear Ms. Moultrie,
SupOff:000006
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
7/26
//C|/...20from%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Correspondence%2012.13.10.htm[08/04/2011 4:00
hank you for your email regarding the annual limit waiver request that was filed by the Superior Officers Council Health and
Welfare Fund (the "Fund"). As requested, we are attaching the spreadsheet that your office provided, detailing information
pplicable to the Fund's prescription drug benefits, for which the Fund has requested a waiver of the annual limit that is curren
ffect.
n response to your specific questions, please note:
. As detailed in the Fund's attestation that accompanied its waiver request, the Fund was in existence prior to March 23, 20
The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147.140; and
. The Fund is not established pursuant to the Taft-Hartley Act, which applies only to benefit plans that arejointly maintained
nions and employers, and which are governed by a joint board of trustees comprising an equal number of employer and union
ustees. Rather, the Fund was established and is maintained by the Captains Endowment Association and the Lieutenants
enevolent Association (the "Unions") to provide supplemental benefits -- such as prescription drug coverage -- to collectively
argained employees of New York City who are represented by the Unions. The supplemental benefits provided by the Fund
prescription drug, dental, vision, hearing aid, and death) are not covered by the City of New York's plan for such employees.
ccordingly, the Unions established the Fund to fill in this "gap" in coverage, and to ensure that collectively bargained employe
eceive coverage for these important health benefits. The Fund provides these benefits with contributions from the City, negoti
etween the Unions and the City.
hope this information is helpful. If you have any questions or need anything else, please contact Mark Nielsen or me. Mark c
e reached at 202.861.5429, and I can be reached at 202.861.2602.
est regards,
nubhav Gogna
Groom Law Group, Chartered
Anubhav Gogna / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-2602 /Fax: 202-659-4503
www.Groom.com/[email protected]
rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 08, 2010 7:47 PMo: Gogna, Anubhav ([email protected])c: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Superior Officers Council Health and Welfare Fund
Dear Mr. Gogna,
hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:
I. Please complete the entire annual limits spreadsheet attached to the email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet donot pertain to your plan, please write None, and/or provide an explanation regarding why you are unabto complete that particular cell in a separate document.
II. In addition, please provide the following information:
Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with
grandfathering provisions, pursuant to 45 CFR 147.140?
Confirm whether the plan was created pursuant to the Taft-Hartley Act.
SupOff:000007
Document obtained by CompleteColorado.com
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/7/27/2019 Superior Officers Council - Redacted Bates HW
8/26
//C|/...20from%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Correspondence%2012.13.10.htm[08/04/2011 4:00
n order to complete your application, please provide this information by 5:00 pm, December 10, 2010. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi
hank you.
am Lynne Moultrie
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
301) 492-4174
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
otice: This message is intended only for use by the person or entity to which it is addressed. Because it may contain confiden
formation intended solely for the addressee, you are notified that any disclosing, copying, downloading, distributing, or retainin
his message, and any attached files, is prohibited and may be a violation of state or federal law. If you received this message
rror, please notify the sender by reply mail, and delete the message and all attached files.
o comply with U.S. Treasury Regulations, we also inform you that, unless expressly stated otherwise, any tax advice containe
his communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenode, and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres
this communication.
SupOff:000008
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
9/26
//C|/...%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Request%20for%20info%2012.8.10.htm[08/04/2011 4:00:
rom: Moultrie, Cam (HHS/OCIIO)ent: Wednesday, December 08, 2010 7:47 PM
To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Superior Officers Council Health and Welfare Fund
Attachments: Waiver Application Form 12-8-10.xlsDear Mr. Gogna,
hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:
I. Please complete the entire annual limits spreadsheet attached to the email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet donot pertain to your plan, please write None, and/or provide an explanation regarding why you are unabto complete that particular cell in a separate document.
II. In addition, please provide the following information:
Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with
grandfathering provisions, pursuant to 45 CFR 147.140?
Confirm whether the plan was created pursuant to the Taft-Hartley Act.
n order to complete your application, please provide this information by 5:00 pm, December 10, 2010. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi
hank you.
am Lynne Moultrie
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
301) 492-4174
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
SupOff:000009
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
10/26
ANNUAL LIMIT WAIVER APPLICATION 2010
al
Waiverest
c ante
Policy Name
(use a newrow for each
policyapplication)
Applic ant
(Plan/ PolicySitus) City
Applic ant
(Plan/Policy
Situs)State
Plan/ Policy
Effective Date(mm/dd/yyyy)
ContactName
StreetAddress City State Zip Code
PhoneNumber
(includingarea code)
EmailAddress
Type of
Coverage(e.g., Limited
Benefit, HRA,Rx only, Other)
Self-
Insured(Yes/No)
Individual orGroup Policy
Total
Number ofIndividualsCovered by
Policy(include all
dependentscovered)
Current
Plan OverallAnnual
Limit (indollars)
plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe
100 ABCDrive Washington DC 20201
1-800-ABC-1234
[email protected] Limited Benefit Yes Group 4,000 $100,000
plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe
100 ABCDrive Washington DC 20202
1-800-ABC-1234
[email protected] Limited Benefit Yes Group 2,500 $100,000
Disclosure Statement
ording to the Paperwork Reductio n Act of 1995, no person s are required to respond to a collection of inform ation unless it displays a valid OMB control number . The valid OMB control number fo r thismation collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions,ch existing data resources, gather the data needed, and complete and review the inf ormation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions foroving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
SupOff:000010
Document obtained by CompleteColorado.com
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]7/27/2019 Superior Officers Council - Redacted Bates HW
11/26
ANNUAL LIMIT WAIVER APPLICATION 2010
mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn
Mental Health/
SubstanceAbuse
Rehabilitative/Devices
Preventive/Wel ln es s Pr es cr ip ti on
PlanDeductible
Copay (if
applicable)
Coinsuranc
e (ifapplicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
C
a
None None None None None None None None None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00
None None None None None None None None None $3,000.00 $1,000.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00
Office VisitCopays/Coinsurance
Hospital InpatientCopay/Coinsurance
Emergency RoomCopay/CoinsuranceCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)
RxCopay/Con
SupOff:000011
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
12/26
ANNUAL LIMIT WAIVER APPLICATION 2010
idual/ Employee
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Projected Rate Increasethat would result from
compliance with $750,000Annual L imit Restric tion
(in do llars)(Average
Premium by Individual)(Difference of Column AT
and AQ divided byColumn AQ)
Access t o
Benefits that
would resultfrom
compliancewith $750,000Annual L imit
Restriction(describe
briefly in cellor in a
PlanAdmini strator/ CEO
of HealthInsuranc
e IssuerName
Title of Individual
ProvidingAttest ation
Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800.00 $925.00 21.71% None Jane Doe Plan Administrator
ployee + Family $105.00 $1,100.00 $1,205.00 $115.00 $1,150.00 $1,265.00 $150.00 $1,400.00 $1,550.00 22.53% None Jane Doe Plan Administrator
Projected Rate Increase that would result
from compliance with $750,000 Annual LimitRestriction (in d ollars) (Average Premium by
Individual)*Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:
Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted
(in dollars)*
* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums are a range based on years of service or age) and by tier (Employee, Employee + Spouse, Employee + Child, Family,etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).
SupOff:000012
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
13/26
//C|/...uperior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Request%20for%20info%20response%2012.13.10.htm[08/04/2011 4:00
rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 13, 2010 1:42 PM
To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)
Attachments: Superior Officers Council Welfare Fund Waiver Application Form 12-9-10.xls
am Lynne Moultrieffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
301) 492-4174
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
rom: Gogna, Anubhav ([email protected]) [mailto:[email protected]]ent: Thursday, December 09, 2010 9:53 AMo: Moultrie, Cam (HHS/OCIIO)c: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected])ubject: RE: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)
ear Ms. Moultrie,
hank you for your email regarding the annual limit waiver request that was filed by the Superior Officers Council Health and
Welfare Fund (the "Fund"). As requested, we are attaching the spreadsheet that your office provided, detailing informationpplicable to the Fund's prescription drug benefits, for which the Fund has requested a waiver of the annual limit that is curren
ffect.
n response to your specific questions, please note:
. As detailed in the Fund's attestation that accompanied its waiver request, the Fund was in existence prior to March 23, 20
The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147.140; and
. The Fund is not established pursuant to the Taft-Hartley Act, which applies only to benefit plans that arejointlymaintained
nions and employers, and which are governed by a jointboard of trustees comprising an equal number of employer and union
ustees. Rather, the Fund was established and is maintained by the Captains Endowment Association and the Lieutenants
enevolent Association (the "Unions") to provide supplemental benefits -- such as prescription drug coverage -- to collectivelyargained employees of New York City who are represented by the Unions. The supplemental benefits provided by the Fund
prescription drug, dental, vision, hearing aid, and death) are not covered by the City of New York's plan for such employees.
ccordingly, the Unions established the Fund to fill in this "gap" in coverage, and to ensure that collectively bargained employe
eceive coverage for these important health benefits. The Fund provides these benefits with contributions from the City, negoti
etween the Unions and the City.
hope this information is helpful. If you have any questions or need anything else, please contact Mark Nielsen or me. Mark c
e reached at 202.861.5429, and I can be reached at 202.861.2602.
est regards,
nubhav Gogna
SupOff:000013
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
14/26
//C|/...uperior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Request%20for%20info%20response%2012.13.10.htm[08/04/2011 4:00
Groom Law Group, Chartered
Anubhav Gogna / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-2602 /Fax: 202-659-4503
www.Groom.com/[email protected]
rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 08, 2010 7:47 PMo: Gogna, Anubhav ([email protected])c: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Superior Officers Council Health and Welfare Fund
Dear Mr. Gogna,
hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:
I. Please complete the entire annual limits spreadsheet attached to the email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet do
not pertain to your plan, please write None, and/or provide an explanation regarding why you are unabto complete that particular cell in a separate document.
II. In addition, please provide the following information:
Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with
grandfathering provisions, pursuant to 45 CFR 147.140?
Confirm whether the plan was created pursuant to the Taft-Hartley Act.
n order to complete your application, please provide this information by 5:00 pm, December 10, 2010. Once this
nformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi
hank you.
am Lynne Moultrie
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
301) 492-4174
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
SupOff:000014
Document obtained by CompleteColorado.com
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/7/27/2019 Superior Officers Council - Redacted Bates HW
15/26
//C|/...uperior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Request%20for%20info%20response%2012.13.10.htm[08/04/2011 4:00
otice: This message is intended only for use by the person or entity to which it is addressed. Because it may contain confiden
formation intended solely for the addressee, you are notified that any disclosing, copying, downloading, distributing, or retainin
his message, and any attached files, is prohibited and may be a violation of state or federal law. If you received this message
rror, please notify the sender by reply mail, and delete the message and all attached files.
o comply with U.S. Treasury Regulations, we also inform you that, unless expressly stated otherwise, any tax advice containe
his communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Reven
ode, and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres
this communication.
SupOff:000015
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
16/26
//C|/...Council%20Health%20and%20Welfare%20Fund%20Annual%20Limit%20Waiver%20Application%20Dec%2020%202010.htm[08/04/2011 4:00
rom: Machado, Juan (HHS/OCIIO)
ent: Monday, December 20, 2010 11:28 AM
o: '[email protected]'
c: Sheer, Jennifer (HHS/OCIIO); '[email protected]'; '[email protected]'
ubject: Superior Officers Council Health and Welfare Fund Annual Limit Waiver Application
ttachments: Waiver Application Form.xls
Dear Mr. Mazawey,
hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:
I. Please complete the entire annual limits spreadsheet, [attached to the email] [and available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html]. Please return the completed spreadshto this email address as an attachment. We will only be able to process spreadsheets that are fully comp(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain tyour plan, please write None, and/or provide an explanation regarding why you are unable to completethat particular cell in a separate document.
II. In addition, please provide the following information:
Please confirm whether or not your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711
the PHS Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the casenon-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limmay add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. your plan does contain a lifetime limit please confirm whether this lifetime limit will be eliminated from yoplan.
Confirm whether the plan was created pursuant to the Taft-Hartley Act.
n order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi
hank you.
uan Machado
rogram Analyst
ffice of Consumer Information and Insurance Oversight
epartment of Health & Human ServicesMD Office: (301) 492-4240
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distrib
or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
SupOff:000016
Document obtained by CompleteColorado.com
http://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html7/27/2019 Superior Officers Council - Redacted Bates HW
17/26
//C|/...om%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Question%20response%201.14.11.htm[08/04/2011 4:00
rom: Pham, Erica (HHS/OCIIO)ent: Friday, January 14, 2011 11:11 AM
To: Nielsen, Mark ([email protected]); Machado, Juan (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)
ubject: RE: Superior Officers Council Health & Welfare Fundark:
uperior Officers' Council should receive an email today for an approval of the plan. We apologize in the delay in getting the leto the plan. Please let us know if you have any additional questions.
est,rica
rom: Nielsen, Mark ([email protected]) [[email protected]]ent: Thursday, January 13, 2011 10:25 PMo: Machado, Juan (HHS/OCIIO); Pham, Erica (HHS/OCIIO)ubject: RE: Superior Officers Council Health & Welfare Fund
ear Erica,
it possible to get confirmation as to the waiver application for the Superior Officers' Council fund? Any assistance you can
rovide would be most appreciated. Thanks--and please feel free to call me if you have any questions or need anything.
est regards,
Mark C. Nielsen
Mark C. Nielsen / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-5429 /Fax: 202-659-4503
www.Groom.com/ [email protected]
rom: Machado, Juan (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 10, 2011 9:26 AMo: Pham, Erica (HHS/OCIIO)
c: Nielsen, Mark ([email protected])ubject: Superior Officers Council Health & Welfare Fund
i Erica,
have included Mark Nielsen who filed the waiver application for Superior Officers Council Health & Welfare Fund on this
mail. He has yet to receive the status of this particular waiver application. Although our records indicate that a status
pdate was sent, would it be possible to send a follow-up to confirm?
hanks for your help,
uan
uan Machado
rogram Analyst
ffice of Consumer Information and Insurance Oversight
epartment of Health & Human Services
MD Office: (301) 492-4240NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distrib
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
SupOff:000017
Document obtained by CompleteColorado.com
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/7/27/2019 Superior Officers Council - Redacted Bates HW
18/26
//C|/...om%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Question%20response%201.14.11.htm[08/04/2011 4:00
otice: This message is intended only for use by the person or entity to which it is addressed. Because it may contain confiden
formation intended solely for the addressee, you are notified that any disclosing, copying, downloading, distributing, or retainin
his message, and any attached files, is prohibited and may be a violation of state or federal law. If you received this message
rror, please notify the sender by reply mail, and delete the message and all attached files.
o comply with U.S. Treasury Regulations, we also inform you that, unless expressly stated otherwise, any tax advice containe
his communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Reven
ode, and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres
this communication.
SupOff:000018
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
19/26
ANNUAL LIMIT WAIVER APPLICATION 2010
al
Waiverest
c ante
Policy Name
(use a newrow for each
policyapplication)
Applic ant
(Plan/ PolicySitus) City
Applic ant
(Plan/Policy
Situs)State
Plan/ Policy
Effective Date(mm/dd/yyyy)
ContactName
StreetAddress City State Zip Code
PhoneNumber
(includingarea code)
EmailAddress
Type of
Coverage(e.g., Limited
Benefit, HRA,Rx only, Other)
Self-
Insured(Yes/No)
Individual orGroup Policy
Total
Number ofIndividualsCovered by
Policy(include all
dependents
Current
Plan OverallAnnual
Limit (indollars)
periorficers
ouncillth andelfareund Plan 1 New York NY
1/1/2011Plan Year
Mark C.Nielsen;
AnubhavGogna
1701Pennsylvania
Avenue,N.W. Washington DC 20006
202-861-5429; 202-
861-2602 mcn@groom. Limited Benef i t Yes Group None
Disclosure Statement
ording to the Paperwork Reductio n Act of 1995, no person s are required to respond to a collection of inform ation unless it displays a valid OMB control number . The valid OMB control number fo r thismation collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions,ch existing data resources, gather the data needed, and complete and review the inf ormation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions foroving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
SupOff:000019
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
20/26
ANNUAL LIMIT WAIVER APPLICATION 2010
mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn
Mental Health/
SubstanceAbuse
Rehabilitative/Devices
Preventive/Wel ln es s Pr es cr ip ti on
PlanDeductible
Copay (if
applicable)
Coinsuranc
e (ifapplicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicabl
C
a
None None None None None None None None None $0.00 $0.00 0.00% $0.00 0.00% $0.00 0.00%
Office VisitCopays/Coinsurance
Hospital InpatientCopay/Coinsurance
Emergency RoomCopay/CoinsuranceCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)
RxCopay/Con
SupOff:000020
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
21/26
ANNUAL LIMIT WAIVER APPLICATION 2010
idual/ Employee
Employee
contribution(if applicable)
Employer
contribution
Employee
contribution(if applicable)
Employer
contribution
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Projected Rate Increasethat would result from
compliance with $750,000Annual L imit Restric tion
(in do llars)(Average
Premium by Individual)(Difference of Column AT
and AQ divided byColumn AQ)
Access t o
Benefits that
would resultfrom
compliancewith $750,000Annual L imit
Restriction(describe
briefly in cellor in a
PlanAdmini strator/ CEO
of HealthInsuranc
e IssuerName
Title of Individual
ProvidingAttest ation
pl oye e + F ami ly $0 .00 $0.00 $0.00
Christopher
Monahan Trustee
$0.00
Projected Rate Increase that would result
from compliance with $750,000 Annual LimitRestriction (in d ollars) (Average Premium by
Individual)*Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:
Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted
(in dollars)*
* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums are a range based on years of service or age) and by tier (Employee, Employee + Spouse, Employee + Child, Family,etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).
SupOff:000021
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
22/26
//C|/...D%201%20from%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Approval%201.14.11.txt[08/04/2011 4:00
rom: Botwinick, Alexandra (HHS/OCIIO)ent: Friday, January 14, 2011 11:07 AMo: [email protected]; Habit, Sandra (HHS/OCIIO)
Cc: [email protected]: Superior Officers Council Health and Welfare Fund Waiver of the
Annual Limits Requirements of PHS Act Section 2711
mportance: High
Attachments: Updated Jan 1 Approval Letter .pdf
Good Morning,
hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2or Superior Officers Council Health and Welfare Fund. HHS has reviewed your application and made itsetermination. Please see the attached letter.
lease confirm receipt of this letter by replying to this e-mail.
lease let me know if I can be of further assistance.
incerely,
Alexandra Botwinick
Office of OversightHHS/[email protected]
SupOff:000022
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
23/26
//C|/...O/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Approval%20receipt%201.14.11.htm[08/04/2011 4:0
rom: Nielsen, Mark ([email protected]) [[email protected]]Sent: Friday, January 14, 2011 11:26 AMo: Pham, Erica (HHS/OCIIO); Machado, Juan (HHS/OCIIO)
Cc: Habit, Sandra (HHS/OCIIO)Subject: Re: Superior Officers Council Health & Welfare Fund
Erica,
We received the approval letter. Thanks to both you and Juan!
Mark C. Nielsen / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-5429 /Fax: 202-659-4503
www.Groom.com/ [email protected]
rom: Pham, Erica (HHS/OCIIO) o: Nielsen, Mark ([email protected]); Machado, Juan (HHS/OCIIO) c: Habit, Sandra (HHS/OCIIO) ent: Fri Jan 14 11:10:59 2011ubject: RE: Superior Officers Council Health & Welfare Fund
ark:
uperior Officers' Council should receive an email today for an approval of the plan. We apologize in the delay in getting the let
o the plan. Please let us know if you have any additional questions.
est,rica
rom: Nielsen, Mark ([email protected]) [[email protected]]ent: Thursday, January 13, 2011 10:25 PMo: Machado, Juan (HHS/OCIIO); Pham, Erica (HHS/OCIIO)ubject: RE: Superior Officers Council Health & Welfare Fund
ear Erica,
it possible to get confirmation as to the waiver application for the Superior Officers' Council fund? Any assistance you canrovide would be most appreciated. Thanks--and please feel free to call me if you have any questions or need anything.
est regards,
Mark C. Nielsen
Mark C. Nielsen / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-5429 /Fax: 202-659-4503 www.Groom.com/ [email protected]
rom: Machado, Juan (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 10, 2011 9:26 AM
o: Pham, Erica (HHS/OCIIO)c: Nielsen, Mark ([email protected])ubject: Superior Officers Council Health & Welfare Fund
i Erica,
have included Mark Nielsen who filed the waiver application for Superior Officers Council Health & Welfare Fund on this
mail. He has yet to receive the status of this particular waiver application. Although our records indicate that a status
pdate was sent, would it be possible to send a follow-up to confirm?
hanks for your help,
SupOff:000023
Document obtained by CompleteColorado.com
http://www.groom.com/http://www.groom.com/mailto:[email protected]://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/mailto:[email protected]://www.groom.com/7/27/2019 Superior Officers Council - Redacted Bates HW
24/26
//C|/...O/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Approval%20receipt%201.14.11.htm[08/04/2011 4:0
uan
uan Machado
rogram Analyst
ffice of Consumer Information and Insurance Oversight
epartment of Health & Human Services
MD Office: (301) 492-4240NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:
his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distrib
copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
otice: This message is intended only for use by the person or entity to which it is addressed. Because it may contain confiden
formation intended solely for the addressee, you are notified that any disclosing, copying, downloading, distributing, or retainin
his message, and any attached files, is prohibited and may be a violation of state or federal law. If you received this message
rror, please notify the sender by reply mail, and delete the message and all attached files.
o comply with U.S. Treasury Regulations, we also inform you that, unless expressly stated otherwise, any tax advice containe
his communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Reven
ode, and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres
this communication.
SupOff:000024
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
25/26
SupOff:000025
Document obtained by CompleteColorado.com
7/27/2019 Superior Officers Council - Redacted Bates HW
26/26
Document obtained by CompleteColorado.com