UFCW Local 1500 - Redacted Bates HW

7/27/2019 UFCW Local 1500 - Redacted Bates HW

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Pages 4 through 9 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4


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From: Kottenmeier, Erika (HHS/OCIIO)Sent: Wednesday, December 15, 2010 3:33 PMTo: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)Subject: Annual Limits Waiver Application

Attachments: Copy of Waiver Application Form.xlsDear Mr. Both,

Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (P

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 spreadshee

address as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., evcontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please wr

and/or provide an explanation regarding why you are unable to complete that particular cell in a separate

II. In addition, please provide the following information:

1. Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance

grandfathering provisions, pursuant to 45 CFR 147.140?

2. Confirm whether the plan was created pursuant to the Taft-Hartley Act and if so, on what date does

collective bargaining agreement pursuant to which the plan was negotiated expire.

In order to complete your application, please provide this information by 5:00 pm, December 17, 2010. Once this infreceived and the application is complete, it will be processed by the Department of Health and Human Services (HH

in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a comple

You will receive an e-mail from HHS notifying you of the waiver decision.


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From: Kottenmeier, Erika (HHS/OCIIO)Sent: Sunday, December 19, 2010 2:41 PMTo: Habit, Sandra (HHS/OCIIO)Subject: FW: Local 1500 Welfare Fund - PT Waiver

Attachments: Waiver Application Form UFCW Local 1500 PT Plan Revised.xls; Waiver Letter001.pdfThanks Sandy! Happy Holidays J

From: Jennifer Viran [mailto:[email protected]]Sent: Friday, December 17, 2010 4:40 PMTo: Kottenmeier, Erika (HHS/OCIIO)Cc: 'Judith Broach'; 'Maria Maloney'; 'Ryk Tierney'Subject: Local 1500 Welfare Fund - PT Waiver

Dear Erika:

Attached is a revised spreadsheet on the Waiver Application. Were sorry for any inconvenience this may have c

Thanks,

Bruce W. Both

Plan Mgr.

UFCW Local 1500


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From: Habit, Sandra (HHS/OCIIO)Sent: Thursday, December 30, 2010 5:21 PMTo: '[email protected]'Subject: UFCW Local 1500 Welfare Fund Approval Letter for a Waiver of the Annual Limits Requireme2010

Importance: High

Attachments: Updated Jan 1 Approval Letter .pdf

Good Afternoon,

Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PH

Section 2711 for UFCW Local 1500 Welfare Fund. HHS has reviewed your application and made

determination. Please see the attached letter.

Please confirm receipt of this letter by replying to this e-mail.

Please let me know if I can be of further assistance.

Sincerely,

Sandy Habit

Department of Health and Human Services

Offi f C I f i d I O i h


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From: [email protected]: Monday, January 03, 2011 9:45 AMTo: Habit, Sandra (HHS/OCIIO)Subject: Re: UFCW Local 1500 Welfare Fund Approval Letter for a Waiver of the Annual Limits Requi30-2010

Sandy Habit,

I am in receipt of your letter approving the request for waiver of the annual limits requirements of PHS section 2711

Bruce Wm. Both

-----Original Message-----

From: Habit, Sandra (HHS/OCIIO) (HHS/OCIIO) To: '[email protected]'

Sent: Thu, Dec 30, 2010 5:21 pm

Subject: UFCW Local 1500 Welfare Fund Approval Letter for a Waiver of the Annual Limits Requirements 12-30-201

Good Afternoon,

Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PH

Section 2711 forUFCW Local 1500 Welfare Fund.

HHS has reviewed your application and made determination. Please see the attached letter.

Please confirm receipt of this letter by replying to this e-mail.


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ANNUAL LIMIT WAIVER APPLICATION 2010

Page 1 of 8

Annual

Limit WaiverRequest

Applic antName

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)

Cur

Plan OAn

Limdol

UFCW Local

1500 Welfare

Fund

Part Time

Employees

Group Benefit

Plan

Queens

Village NY 01/01/2011 Bruce Both

425 Merrick

Ave Westbury NY 11590

1-800-522-

0456

bboth1500@

aol.com Limited Benefit Yes Group

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


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Page 2 of 8

Annual

Limit WaiverRequest

Applic antName

Policy Name


policyapplication)

UFCW Local

1500 Welfare

Fund

Part Time

Employees

Group Benefit

Plan

Ambulat 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)

C

a

Office VisitCopays/Coinsurance CCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)

UF


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Page 3 of 8

Annual

Limit WaiverRequest

Applic antName

Policy Name


policyapplication)

UFCW Local

1500 Welfare

Fund

Part Time

Employees

Group Benefit

Plan

Coinsurance (if

applicable)

Copay (if

applicable)

Coinsuran

ce (ifapplicable)

Individual/ EmployeeTier*

Employee

contribution(if applicable)

Employer

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

Employee


Employer


Employee


Employer


Projected Rate Incrthat would result f

compliance with $75Annual L imit Restri

(in dol lars)(Avera

Premium by Individ(Difference of Colum

and AQ divided bColumn AQ)

Projected Rate Increase that would result

from compliance with $750,000 Annual LimitRestriction (in d ollars) (Average Premium by

Individual)*cy Roominsurance

Current Monthly Premium Rates orPremium Equivalent Rates (in dollars)*:

RxCopay/Coninsurance

Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted

(in dollars)*

UF


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Page 4 of 8

AnnualLimit WaiverRequest

Applic antName

Policy Name(use a newrow for each

policyapplication)

UFCW Local

1500 Welfare

Fund

Part Time

Employees

Group Benefit

Plan

Title of Individual

ProvidingAttest ation

Plan Administrator

UF


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Page 5 of 8

AnnualLimit Waiver

RequestApplic ant

Name

Policy Name(use a new

row for eachpolicy

application)

Applic ant(Plan/ Policy

Situs) City

Applic ant(Plan/

PolicySitus)

State

Plan/ PolicyEffective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City State Zip Code

Phone

Number(including

area code)

Email

Address

Type ofCoverage

(e.g., LimitedBenefit, HRA,

Rx only, Other)

Self-Insured(Yes/No)

Individual or

Group Policy

TotalNumber ofIndividuals

Covered byPolicy

(include alldependents

covered)

CurPlan O

AnLim

dol

PRA Disclosure Statement

According to the Paper work Reduction Act of 1995, no persons are required to res pond to a collectio n of information unless it displays a valid OMB control num ber. The valid OMB control number for thisinformation 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,search 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 forimproving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

UF


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Page 6 of 8

AnnualLimit Waiver

RequestApplic ant

Name


row for eachpolicy

application)


According to the Pap erworkinformation collection is 093search existing data resourcimproving this form, please

Ambulat 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)

Ca

UF


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Page 7 of 8

AnnualLimit Waiver

RequestApplic ant

Name


row for eachpolicy

application)


According to the Pap erworkinformation collection is 093search existing data resourcimproving this form, please

Coinsura

nce (ifapplicabl

e)

Copay (ifapplicabl

e)

Coinsurance (if

applicable)

Individual/ Employee

Tier*

Employeecontribution

(if applicable)

Employercontribution

(i f ap pl ic ab le) To tal


(if applicable)




(if applicable)



Projected Rate Incr

that would result fcompliance with $75Annual L imit Restri

(in dol lars)(AveraPremium by Individ

(Difference of Columand AQ divided b

Column AQ)

* 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).

UF


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Page 8 of 8

AnnualLimit Waiver

RequestApplic ant

Name


row for eachpolicy

application)


According to the Paperworkinformation collection is 093search existing data resourcimproving this form, please

Title of IndividualProviding

Attest ation

UF

UFCW Local 1500 - Redacted Bates HW

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