Arc Onondaga-Redacted HW

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Pages 3 through 18 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption (b)(4)

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ANNUAL LIMIT WAIVER APPLICATION 2010

alWaiver

estc ante

Policy Name(use a new

row for eachpolicyapplication)

Applic ant(Plan/ PolicySitus) City

Applic ant(Plan/

PolicySitus)State

Plan/ PolicyEffective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City State Zip Code

Phone

Number(includingarea code)

EmailAddress

Type ofCoverage

(e.g., LimitedBenefit, HRA,

Rx only, Other)

Self-Insured(Yes/No)

Individual orGroup Policy

TotalNumber ofIndividuals

Covered byPolicy

(include alldependents

covered)

CurrentPlan Overall

AnnualLimit (in

dollars)

plicantHRA Plan A Bethesda MD 01/01/2011 John Doe

100 HRADrive Bethesda MD 20814

1-800-HRA-1234

[email protected] HRA Yes Group 50 $3,500

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.

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mailto:[email protected]:[email protected]:[email protected]:[email protected]


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mbulat ory Emergency Hospit alization Laborat ory Pediatric

Maternity/

Newborn

Mental Health/Substance

Abuse

Rehabilitative/

Devices

Preventive/

Wel ln es s Pr es cr ip ti on

Plan

Deductible

Copay (ifapplicabl

e)

Coinsurance (if

applicable)

Copay (ifapplicabl

e)

Coinsura

nce (ifapplicabl

e)

Copay (ifapplicabl

e)

Coinsura

nce (ifapplicabl

e)

Copay (ifapplicabl

e)

C

a

None None None None None None None None None None $0.00 $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.00

Current Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)

Rx

Copay/Con

Office Visit

Copays/Coinsurance

Hospital Inpatient

Copay/Coinsurance

Emergency Room

Copay/Coinsurance

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idual/ EmployeeEmployee

contribution

(if applicable)

Employercontribution

(i f ap pl ic ab le) To tal

Employeecontribution

(if applicable)


(i f ap pl ic ab le) To tal

Employeecontribution

(if applicable)


( if ap pl ic ab le) To tal

Projected Rate Increase

that would result fromcompliance with $750,000Annual L imit Rest rict ion

(in do llars)(AveragePremium by Individual)

(Difference of Column ATand AQ divided by

Column AQ)

Access t o

Benefits thatwould result

fromcompliance

with $750,000

Annual L imitRestriction

(describebriefly in cell

or in a

PlanAdmini str

ator/ CEOof Health

Insurance IssuerName

Title of IndividualProviding

Attest ation

Employee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00"HRA plan will

terminate." John Doe Plan Administrator

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted

(in dollars)*

Projected Rate Increase that would resultfrom compli ance with $750,000 Annual LimitRestriction (in d ollars) (Average Premium by

Individual)*

* 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).

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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Waiver.txt[10/31/2011 11:42:06 PM]

rom: Jessica Seals [[email protected]]ent: Wednesday, December 01, 2010 3:11 PMo: HHS HealthInsurance (HHS)ubject: Waiver

Attachments: WLBRHRBH20020101201150500.pdf

ollow Up Flag: Follow uplag Status: Completed

Waiver request from Arc of Onondaganclosed please find:) Written request for Waiver) Summary Plan Description) Summary of Material Modification

-----------------------------essica Seals, Director of Human Resources: [email protected] | V: (315) 476-7441x 1173 | F: (315) 472-0873 |

W: www.arcon.org

Arc of Onondaga00 South Wilbur Avenueyracuse, New York 13204

Mission Statement: Arc of Onondaga assists individuals with developmentalisabilities achieve their fullest potential.

his message is intended for the sole use of the

ndividual and entity to which it is addressed

nd may contain information that is privileged,

onfidential, and exempt from disclosure under

pplicable law.

f you are not the recipient, nor authorized to

eceive for recipient, you are hereby notified

hat you may not use, copy, disclose or distribute

o anyone the message or any information

ontained in the message.

f you have received this message in error

lease immediately advise the sender by

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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Waiver.txt[10/31/2011 11:42:06 PM]

eply email and delete the message.

hank you.

Arc of Onondaga is an Equal Opportunity Employer.

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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Approval%201.12.11.htm[10/31/2011 11:42:06 PM]

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Wednesday, January 12, 2011 12:02 PMTo: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Arc of Onondaga Waiver of the Annual Limits Requirements of PHS Act Section 2711

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdfood Morning,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act

ection 2711 for Arc of Onondaga. HHS has reviewed your application and made its determination. Please

he 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

ffice of Oversight

HHS/[email protected]

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mailto:[email protected]:[email protected]


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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Approval%20receipt%201.12.11.htm[10/31/2011 11:42:07 PM]

rom: Jessica [[email protected]]ent: Wednesday, January 12, 2011 1:07 PM

To: Botwinick, Alexandra (HHS/OCIIO); Habit, Sandra (HHS/OCIIO)Cc: [email protected]; [email protected]: Arc of Onondaga Waiver response

Ms. Botwinick:

hank you for your time. We are in receipt of the approval letter sent from HHS regarding our waiver. My direct response to y

mail was bounced back by your server.

you need any further information, please do not hesitate to contact us. We thank you for your assistance

incerely,

essica Seals

----------------------------

essica Seals, Director of Human Resources

:[email protected] | V: (315) 476-7441x 1173 | F: (315) 472-0873 | W: www.arcon.org

rc of Onondaga

00 South Wilbur Avenueyracuse, New York 13204

Mission Statement: Arc of Onondaga assists individuals with developmental disabilities achieve their fullest potential.

ARC ONONDAGA:000014
mailto:[email protected]:[email protected]://www.arcon.org/http://www.arcon.org/mailto:[email protected]


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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Reqeust%20for%20info%2012.22.10.htm[10/31/2011 11:42:07 PM]

rom: Andrews, Jane (HHS/OCIIO)ent: Wednesday, December 22, 2010 1:09 PM

To: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)

ubject: Your application for a waiver of Annual Limits for an HRA

Attachments: HRAspreadsheet.xlsn order to expedite your application, please provide the following information:

lease complete the entire annual limits spreadsheet, (attached to the email). Please return the completed spreadsheo this email address as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., evell should contain the information requested). If a cell on the spreadsheet does not pertain to your plan, please wrNone, and/or provide an explanation regarding why you are unable to complete that particular cell in a separateocument. An example of how to complete the spreadsheet is provided in the first row.

n addition, if you did not submit a signed attestation from the plan administrator, please follow the instructions onttestations provided in the September 3, 2010 guidance, page 3, number 5, and have that scanned to this e-mailddress.

hank you.

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)

02-536-6779 (Blackberry)

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal governmuse only and must not be disseminated, distributed, or copied to persons not authorized to receive the informatio

Unauthorized disclosure may result in prosecution to the full extent of the law.

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