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Pages 28 through 143 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -(b)(4)

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rom: Ann Bender [[email protected]]

ent: Thursday, December 30, 2010 10:50 AM

o: Sheer, Jennifer (HHS/OCIIO)

c: [email protected]

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ollow Up Flag: Follow up

ag Status: Completed

i Jennifer

y stating None in that column, I simply meant that if the Plan was required to change its Annual Limit from

to $750,000 in 2011, the participant would not see a difference in the type or arrangement in how thewould have Access to Benefits.

owever, reading it now, I suppose you could say that if the Plan was required to change its Annual Limit from

to $750,000 in 2011, each individual covered by the Plan would have Access to an additional enefits in 2011.

guess I was confused by whether that cell was looking for a description or a dollar amount. I hope I was able t

nswer your request appropriately.

espectfully,

nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite Boselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Any

nauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender b

mail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]

ent: Thursday, December 30, 2010 7:48 AMo: Ann Benderc:[email protected]: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

i Ann

have received your spreadsheet and would like to request a small clarification. Under the column Access to benefits tha

would result from compliance with $750,000 Annual Limit Restriction you entered None. Please elaborate on what you

mean by this response.

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hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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 n

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecu

to the full extent of the law.

rom: Ann Bender [mailto:[email protected]]ent: Wednesday, December 29, 2010 3:44 PMo: Sheer, Jennifer (HHS/OCIIO)c:[email protected]: FW: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ello Jennifer

lease find attached the spreadsheet you have requested (see below) for the Chicago Tile Institute Welfare Fund

you should have any questions regarding this information, please do not hesitate to contact either Frank Marcmyself.

espectfully,

nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite B

oselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Any

nauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender b

mail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]

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//O|/...go%20Tile%20Institute/Addl%20Info%20Chicago%20Tile%20Institute%20Welfare%20Fund%20Annual%20Limit%20W.htm[10/31/2011 10:15:

ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.

apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Application

nstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.

will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PMo: 'Sheer, Jennifer (HHS/OCIIO)'ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

CHICAGO TILE:000012

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//O|/...go%20Tile%20Institute/Addl%20Info%20Chicago%20Tile%20Institute%20Welfare%20Fund%20Annual%20Limit%20W.htm[10/31/2011 10:15:

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this 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 withgrandfathering provisions, pursuant to 45 CFR 147.140?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PHAct, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to besigned by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan a

the person who signed the statement.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.

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

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ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Thursday, December 30, 2010 11:00 AM

o: 'Ann Bender'

c: [email protected]

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ollow Up Flag: Follow up

ag Status: Flagged

i Ann

can understand your confusion; a description was what we were looking for, and your reply provided just that. Thank you

he clarification.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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 n

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecu

to the full extent of the law.

rom: Ann Bender [mailto:[email protected]]ent: Thursday, December 30, 2010 10:50 AMo: Sheer, Jennifer (HHS/OCIIO)c:[email protected]: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

i Jennifer

y stating None in that column, I simply meant that if the Plan was required to change its Annual Limit from

to $750,000 in 2011, the participant would not see a difference in the type or arrangement in how thewould have Access to Benefits.

reading it now, I suppose you could say that if the Plan was required to change its Annual Limit from

to $750,000 in 2011, each individual covered by the Plan would have Access to an additional enefits in 2011.

guess I was confused by whether that cell was looking for a description or a dollar amount. I hope I was able t

nswer your request appropriately.CHICAGO TILE:000015

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espectfully,

nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite B

oselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Any

nauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender b

mail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 30, 2010 7:48 AMo: Ann Benderc:[email protected]

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

i Ann

have received your spreadsheet and would like to request a small clarification. Under the column Access to benefits tha

would result from compliance with $750,000 Annual Limit Restriction you entered None. Please elaborate on what you

mean by this response.

hank you.

--------------------------------ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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 n

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecu

to the full extent of the law.

rom: Ann Bender [mailto:[email protected]]ent: Wednesday, December 29, 2010 3:44 PMo: Sheer, Jennifer (HHS/OCIIO)c:[email protected]: FW: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

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ello Jennifer

lease find attached the spreadsheet you have requested (see below) for the Chicago Tile Institute Welfare Fund

you should have any questions regarding this information, please do not hesitate to contact either Frank Marc

myself.

espectfully,

nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite B

oselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Anynauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender b

mail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.

apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Application

nstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.

will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

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01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PM

o: 'Sheer, Jennifer (HHS/OCIIO)'ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PM

o: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that ar

CHICAGO TILE:000018

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fully 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan athe person who signed the statement.

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.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Thursday, December 30, 2010 8:48 AM

o: 'Ann Bender'

c: [email protected]

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ollow Up Flag: Follow up

ag Status: Completed

i Ann

have received your spreadsheet and would like to request a small clarification. Under the column Access to benefits tha

would result from compliance with $750,000 Annual Limit Restriction you entered None. Please elaborate on what you

mean by this response.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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 n

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecu

to the full extent of the law.

rom: Ann Bender [mailto:[email protected]]ent: Wednesday, December 29, 2010 3:44 PMo: Sheer, Jennifer (HHS/OCIIO)c:[email protected]: FW: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ello Jennifer

lease find attached the spreadsheet you have requested (see below) for the Chicago Tile Institute Welfare Fund

you should have any questions regarding this information, please do not hesitate to contact either Frank Marc

myself.

espectfully,

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nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite B

oselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Any

nauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender bmail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.

apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Application

nstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.

will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank MarcoCHICAGO TILE:000021

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regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PMo: 'Sheer, Jennifer (HHS/OCIIO)'

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marco

c: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this 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 unab

to 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit m

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add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan athe person who signed the statement.

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 Hum

ervices (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.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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rom: Frank A. Marco [[email protected]]

ent: Thursday, December 09, 2010 6:36 PM

o: Sheer, Jennifer (HHS/OCIIO)

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan a

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the person who signed the statement.

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.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Friday, December 10, 2010 8:21 AM

o: 'Frank A. Marco'

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ttachments: Waiver Application Form.xls

ood morning.

apologize for the lack of attachment to my initial e-mail; please find the file attached to this message. Thank you for

nswering the questions below; with the information regarding your relationship to the plan, I do not believe that further

ttestation is necessary.

lease feel free to contact me if you have any questions.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Thursday, December 09, 2010 6:36 PMo: Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)

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ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that ar

fully 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-

essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan athe person who signed the statement.

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 3

ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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Pages 165 through 186 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -(b)(4)

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rom: Frank A. Marco [[email protected]]

ent: Thursday, December 23, 2010 11:46 AM

o: Sheer, Jennifer (HHS/OCIIO)

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ollow Up Flag: Follow up

ag Status: Completed

went to the web site but I could not work the spreadsheet from the web site. Can you email me a copy of it?

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]

ent: Thursday, December 23, 2010 10:09 AMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ear Mr. Marco

When you return your completed spreadsheet, can you please also provide a response to the inquiry below:

As a Taft-Hartley plan:

o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008.

o Please provide the date for which the Collective Bargaining Agreement will expire.

you have more than one CBA in effect, please answer the above for each CBA.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 3:38 PMo: Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

hank you.

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Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.

apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Applicationnstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.

will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

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rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PMo: 'Sheer, Jennifer (HHS/OCIIO)'ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan athe person who signed the statement.

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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.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Thursday, December 23, 2010 11:09 AM

o: 'Frank A. Marco'

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ollow Up Flag: Follow up

ag Status: Completed

ear Mr. Marco

When you return your completed spreadsheet, can you please also provide a response to the inquiry below:

As a Taft-Hartley plan:

o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008.

o Please provide the date for which the Collective Bargaining Agreement will expire.

you have more than one CBA in effect, please answer the above for each CBA.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 3:38 PMo: Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

hank you.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.CHICAGO TILE:000036

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apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Application

nstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.

will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PMo: 'Sheer, Jennifer (HHS/OCIIO)'ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

CHICAGO TILE:000037

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Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]

ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that ar

fully 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-

essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan athe person who signed the statement.

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 3

ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

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[email protected]

01-492-4487

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Thursday, December 16, 2010 2:48 PM

o: Frank A. Marco

c: Sheer, Jennifer (HHS/OCIIO)

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ollow Up Flag: Follow up

ag Status: Completed

ood afternoon.

wanted to follow up with you and make sure that you were able to access the file either through my attachment or the websitease let me know if you were able to access it or if you are continuing to have problems with it.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [[email protected]]ent: Wednesday, December 15, 2010 3:38 PMo: Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

hank you.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.

apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Application

nstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.CHICAGO TILE:000040

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will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight.S. Department of Health and Human Services

[email protected]

01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PMo: 'Sheer, Jennifer (HHS/OCIIO)'ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marco

regorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected] TILE:000041

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//O|/...icago%20Tile%20Institute/Checking%20on%20Attach%20Chicago%20Tile%20Institute%20Welfare%20Fund%20Annua.htm[10/31/2011 10:15:

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PMo: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this 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 withgrandfathering provisions, pursuant to 45 CFR 147.140?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan a

the person who signed the statement.

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.

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

ennifer L. O. Sheerffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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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)

ContactName

StreetAddress City State Zip Code

Phone

Number(includingarea code)

EmailAddres s

Type ofCoverage

(e.g., LimitedBenefit, HRA,

Rx only, Other)

Self-Insured(Yes/No)

Individual orGroup Policy

Total

Number ofIndividuals

Covered byPolicy

(include alldependents

covered)

CurrentPlan Overall

AnnualLimit (indollars)

ago Tile

stituteelfare

und

Chicago TileInstitute

Welfare Fund Roselle IL 01/01/2011

Frank MarcoC/O Gregorio

& Associates

2 N LaSalle

St, Ste 1650 Chicago IL 60602

1-312-263-

2343

fmarco@gre

goriolaw.com Limited Benefit Yes Group

Disclosure Statement

rding to the Pap erwork Reduction Act of 1995, no person s are required to re spond to a collect ion of informatio n unless it disp lays a valid OMB c ontrol number. The valid OMB contro l number for thismation collection is 0938-1105. The time required to complete this information collection is estimate d 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 information collec tion. 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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ANNUAL LIMIT WAIVER APPLICATION 2010

mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn

Mental Health/Substance

AbuseRehabilitative/

DevicesPreventive/Wel ln es s Pr es cr ip ti on

PlanDeductible

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

Office Visit

Copays/Coinsurance

Hospital Inpatient

Copay/Coinsurance

Emergency Room

Copay/CoinsuranceCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)

Rx

Copay/Con

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ANNUAL LIMIT WAIVER APPLICATION 2010

idual/ EmployeeEmployee

contribution(if applicable)

Employercontribution

(i f ap pl ic ab le) To tal

Employeecontribution(if applicable)

Employercontribution(i f ap pl ic ab le) To tal

Employeecontribution

(if applicable)

Employercontribution

( 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

ployee + Family AnnBender Plan Administrator

Projected Rate Increase that would resultfrom compli ance 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).

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Pages 204 through 222 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -(b)(4)

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Thursday, December 09, 2010 2:12 PM

o: '[email protected]'

c: Sheer, Jennifer (HHS/OCIIO)

ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this 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 withgrandfathering provisions, pursuant to 45 CFR 147.140?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit madd an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Pleaconfirm whether this lifetime limit will be eliminated from your plan.

The application materials previously submitted to HHS include a certification statement that appears to be

signed by Frank A. Marco. Please confirm that this is correct, and provide the relationship between the plan a

the person who signed the statement.

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.

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

ennifer L. O. Sheerffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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rom: Sheer, Jennifer (HHS/OCIIO)

ent: Monday, January 03, 2011 10:21 AM

o: 'Ann Bender'

c: [email protected]

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Applicant:

hank you for your information. Your application is now complete and you should receive a determination of yourpplication within 30 days.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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 n

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecu

to the full extent of the law.

rom: Ann Bender [mailto:[email protected]]ent: Thursday, December 30, 2010 10:50 AMo: Sheer, Jennifer (HHS/OCIIO)c:[email protected]: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

i Jennifer

None in that column, I simply meant that if the Plan was required to change its Annual Limit from

to $750,000 in 2011, the participant would not see a difference in the type or arrangement in how thewould have Access to Benefits.

reading it now, I suppose you could say that if the Plan was required to change its Annual Limit from

to $750,000 in 2011, each individual covered by the Plan would have Access to an additional n 2011.

guess I was confused by whether that cell was looking for a description or a dollar amount. I hope I was able t

nswer your request appropriately.

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espectfully,

nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite B

oselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Any

nauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender b

mail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 30, 2010 7:48 AMo: Ann Benderc:[email protected]

ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

i Ann

have received your spreadsheet and would like to request a small clarification. Under the column Access to benefits tha

would result from compliance with $750,000 Annual Limit Restriction you entered None. Please elaborate on what you

mean by this response.

hank you.

--------------------------------ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

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 n

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecu

to the full extent of the law.

rom: Ann Bender [mailto:[email protected]]ent: Wednesday, December 29, 2010 3:44 PMo: Sheer, Jennifer (HHS/OCIIO)c:[email protected]: FW: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

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ello Jennifer

lease find attached the spreadsheet you have requested (see below) for the Chicago Tile Institute Welfare Fund

you should have any questions regarding this information, please do not hesitate to contact either Frank Marc

myself.

espectfully,

nn M. Bender, CEBS

hicago Tile Institute Welfare Fund

25 E. Irving Park Road, Suite B

oselle, IL 60172

h (630) 924-4990

ax (630) 924-4991

his email message, including any attachment(s), is for the sole use of the intended recipient(s) and may contain confidential information. Anynauthorized review, use, disclosure or distribution is strictly prohibited. If you are not the intended recipient, please immediately contact the sender b

mail.

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:08 PMo: Frank A. Marcoubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ood afternoon.

apologize that you have not yet received the spreadsheet. I attempted to send it to you on Friday, Dec. 10; however, it is

ear you did not receive the file. I am concerned that perhaps my e-mail did not make it through your filters due to the

ttachment. Therefore, I am sending you this initial reply so you are aware that the attachment will be resent momentari

ou do not receive the spreadsheet this afternoon, you can download it from

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html, where it is listed as Annual Limit Waiver Application

nstructions (PDF - 44KB) (12/8/2010), fill in all the fields, and then return it to me at this email address.

will send you a second reply with the attachment momentarily.

hank you.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

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01-492-4487

rom: Frank A. Marco [mailto:[email protected]]ent: Wednesday, December 15, 2010 2:36 PMo: Frank A. Marco; Sheer, Jennifer (HHS/OCIIO)ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

lease forward me the spreadsheet for our waiver application.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Frank A. Marcoent: Thursday, December 09, 2010 5:36 PM

o: 'Sheer, Jennifer (HHS/OCIIO)'ubject: RE: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

ennifer,

hank you for your response. A spreadsheet was not attached to the email. Please resend and I will complete the document.

With regard to your other inquiries:

. The Plan was in existence prior to March 23, 2010, and is in compliance with the grandfathering provision.

The lifetime limit has been eliminated from the plan as of January 1, 2010.

. I did submit the initial certification as the attorney for the plan. If you, need our administrator to sign off on it, please le

now.

lease let me know if you need anything else. Thank you.

Frank Marcoregorio & Associates

N. LaSalle Street, Suite 1650

hicago, IL 60602

312) 263-2343 Phone

312) 263-2512 Fax

[email protected]

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 09, 2010 1:12 PM

o: Frank A. Marcoc: Sheer, Jennifer (HHS/OCIIO)ubject: Chicago Tile Institute Welfare Fund Annual Limit Waiver Application

Dear Mr. Marco:

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 this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that ar

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fully 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?

In your application, your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711 of the PH

Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or Stat