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Section 105 Standalone Health Reimbursement Arrangement

Summary of Material Modification Effective January 1, 2011

Changes to the Section 105 Plan And Summary Plan Descriptions (SPDs) for Wayne ARCs Health Reimbursement Arrangement (HRA) Plan

are described below.

Standalone Health Reimbursement Arrangement

ARTICLE I PREAMBLE1.2 Purpose of the Plan.The purpose of the Plan shall be to reimburse Participants, subject to certain limitations as prescribed herein, for certain healthexpenses

incurred by them which are not reimbursed in any other manner and which would be covered under the group health insurance program

or programs from time to time sponsored by the Sponsor.

ARTICLE II PARTICIPATION2.1 Eligibility and Enrollment.

ARTICLE III AMOUNT OF BENEFITS

3.1 Benefits Provided by the Plan.Each Participant shall be entitled to reimbursement for the Qualifying Health Expenses incurred by the Participant during the Plan Year,

provided that the same are not reimbursed to the Participant or his or her spouse or Dependents in any other manner, including, but not

limited to, the Health Plan or any other fully or partially insured or self-insured plans or programs requiring the payment of a premium or

other outlay by the Sponsor. If any Participant or his or her spouse or Dependent is partially reimbursed from any other sources with

respect to amounts otherwise eligible for reimbursement hereunder, that portion which is not so reimbursed may be reimbursed

hereunder, subject to the provisions hereof. Reimbursement claims shall be filed and processed as provided in Article V hereof.

Notwithstanding any provision of the Plan to the contrary, no Participants reimbursement for the Qualifying Health Expenses incurred shall

exceed increased by any amount contributed to the Plan and rolled over from a prior year, in accordance with Section 4.2.This Summary of Material Modification (SMM) describes the changes that affect your Health Reimbursement Arrangement (HRA) Plans. SMMstogether with the Section 105 Plan and Summary Plan Description make up your official plan description; please keep them together and referto them as necessary. Weve made every attempt to insure the accuracy of the information in this SMM. However, if there is any discrepancybetween this and the plan document, the plan document will always govern.

Plan Administrator Information The Plan Administrators name and telephone number are:Wayne ARC150 Van BurenNewark NY 14513Telephone: 315-331-7741

The Plan Administrator keeps the records for the Plan and is responsible for the administration of the Plan. The Plan Administrator will alsoanswer any questions you may have about the Plan.

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//T|/...NO%2012600%20Response%20[YELLOW]/Wayne%20ARC%20Standalone%20HRA%20Section%20105%20Plan/Waiver.htm[06/30/2011 4:14

rom: O'Bine, Barbara [Barbara.O'[email protected]]ent: Tuesday, November 23, 2010 9:14 AM

To: HHS HealthInsurance (HHS)ubject: Waiver

Attachments: Wayne ARC SMM 2011 - Section 105.pdf; Wayne Standalone HRA amended and restated 1-1-10 wignature.pdf; DOC112310.pdfood morning,

ttached please find the following documents:

Signed application for waiver from the restricted annual limit requirements for the Wayne ARC Standalone HRA

Wayne ARC HRA Summary of Material Modification effective 1/1/11

Signed Wayne ARC Standalone HRA Amended and Restated effective 1/1/10

lease contact me if you need any other information or if you are having difficulty opening these documents. Thank you f

our consideration of our request.

arbara O'Bine

ssistant Director of HR

Wayne ARC

50 VanBuren Street

ewark, NY 14513

hone (315) 331-7741 X275

ax (315) 331-4857

arbara.o'[email protected]

www.waynearc.org

hi s message i s i nt ended onl y f or t he use of t he i ndi vi dual or ent i t y t o whi ch i t i s addr essednd may cont ai n i nf or mat i on t hat i s pr i vi l eged, conf i dent i al , and exempt f r om di scl osur e underppl i cabl e l aw. I f t he r eader of t hi s message i s not t he i nt ended r eci pi ent or t he empl oyee ogent r esponsi bl e f or del i ver i ng the message to t he i nt ended r eci pi ent , you ar e her eby not i f i ehat any di ssemi nat i on, di st r i but i on, or copyi ng of t hi s communi cat i on i s st r i ctl y pr ohi bi t ed.f you have recei ved t hi s communi cat i on i n er r or , pl ease i mmedi atel y not i f y t he sender and delhi s message.

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//T|/...20[YELLOW]/Wayne%20ARC%20Standalone%20HRA%20Section%20105%20Plan/Request%20for%20info%2012.15.10.htm[06/30/2011 4:15

rom: Moultrie, Cam (HHS/OCIIO)ent: Wednesday, December 15, 2010 3:48 PM

To: [email protected]: [email protected]; Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Wayne Arcear Mr. Reilly,

er Part II B of the Preamble of 26 CFR 54.9815-2711T; 29 CFR 2590.715-2711, and 45 CFR part 147.126, [w]hen HRAs a

ntegrated with other coverage as part of a group health plan, and the other coverage alone would comply with the

equirements of the PHS Act section 2711, the fact that benefits under the HRA by itself are limited does not violate Sectio711 because the combined benefit satisfies the requirements.

lease review your integrated plan to determine whether it is compliant with Section 2711. If your integrated plan is

ompliant, your HRA is not required to obtain a waiver of the annual limit. Please confirm whether you would like HHS to

withdraw your application, or whether you would like HHS to proceed with processing your application.

hank you.

am Lynne Moultrie

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

301) [email protected]

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.

WayneARC000004


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//T|/...20Response%20[YELLOW]/Wayne%20ARC%20Standalone%20HRA%20Section%20105%20Plan/Approval%2012.14.10.htm[06/30/2011 4:15:

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Tuesday, December 14, 2010 12:47 PM

To: 'Barbara.O'[email protected]'ubject: Waiver of the Annual Limits Requirements of PHS Act Section 2711

mportance: High

ollow Up Flag: Follow up

lag Status: Red

Attachments: Updated Jan 1 Approval Letter .pdf

ood Afternoon,

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

ection 2711 for Wayne ARC Standalone HRA Section 105 Plan. HHS has reviewed your application and

made its determination. 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

ffice of Oversight

HHS/[email protected]

WayneARC000005
mailto:[email protected]:[email protected]


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//T|/...]/Wayne%20ARC%20Standalone%20HRA%20Section%20105%20Plan/Confirmation%20of%20Aprpoval%2012-15-2010.htm[06/30/2011 4:15:

rom: O'Bine, Barbara [Barbara.O'[email protected]]ent: Wednesday, December 15, 2010 8:03 AM

To: Botwinick, Alexandra (HHS/OCIIO)ubject: RE: Waiver of the Annual Limits Requirements of PHS Act Section 2711

ollow Up Flag: Follow uplag Status: Bluehank you. We received the email.

rom: Botwinick, Alexandra (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, December 14, 2010 12:47 PMo: O'Bine, Barbaraubject: Waiver of the Annual Limits Requirements of PHS Act Section 2711mportance: High

ood Afternoon,

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

ection 2711 for Wayne ARC Standalone HRA Section 105 Plan. HHS has reviewed your application and

made its determination. 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

ffice of Oversight

HHS/[email protected]

his message is intended only for the use of the individual or entity to which it is addressednd may contain information that is privileged, confidential, and exempt from disclosure underpplicable law. If the reader of this message is not the intended recipient or the employee ogent responsible for delivering the message to the intended recipient, you are hereby notifiehat any dissemination, distribution, or copying of this communication is strictly prohibited.f you have received this communication in error, please immediately notify the sender and delhis message.

WayneARC000006
mailto:[email protected]:[email protected]


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//T|/...sponse%20[YELLOW]/Wayne%20ARC%20Standalone%20HRA%20Section%20105%20Plan/Correspondence%2012.17.10.htm[06/30/2011 4:1

rom: Moultrie, Cam (HHS/OCIIO)ent: Friday, December 17, 2010 11:09 AM

To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for Wayne Arc

am Lynne Moultrie


.S. Department of Health and Human Services301) 492-4174

[email protected]




rom: Reilly, Gary [mailto:[email protected]]ent: Thursday, December 16, 2010 8:04 AMo: Moultrie, Cam (HHS/OCIIO)c: Calhoun, Davidubject: RE: Waiver Application for Wayne Arc

ood morning,

am researching this and will get back to you very soon.

hanks and have a great day.

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 15, 2010 3:48 PMo: Reilly, Garyc: Calhoun, David; Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Wayne Arc

ear Mr. Reilly,

er Part II B of the Preamble of 26 CFR 54.9815-2711T; 29 CFR 2590.715-2711, and 45 CFR part 147.126, [w]hen HRAs a

ntegrated with other coverage as part of a group health plan, and the other coverage alone would comply with the

equirements of the PHS Act section 2711, the fact that benefits under the HRA by itself are limited does not violate Sectio

711 because the combined benefit satisfies the requirements.

lease review your integrated plan to determine whether it is compliant with Section 2711. If your integrated plan is

ompliant, your HRA is not required to obtain a waiver of the annual limit. Please confirm whether you would like HHS to

withdraw your application, or whether you would like HHS to proceed with processing your application.

hank you.

am Lynne Moultrie


.S. Department of Health and Human Services

WayneARC000007


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//T|/...sponse%20[YELLOW]/Wayne%20ARC%20Standalone%20HRA%20Section%20105%20Plan/Correspondence%2012.17.10.htm[06/30/2011 4:1

301) 492-4174

[email protected]




his message is intended only for the use of the individual or entity to which it is addressednd may contain information that is privileged, confidential, and exempt from disclosure underpplicable law. If the reader of this message is not the intended recipient or the employee ogent responsible for delivering the message to the intended recipient, you are hereby notifiehat any dissemination, distribution, or copying of this communication is strictly prohibited.f you have received this communication in error, please immediately notify the sender and delhis message.

WayneARC000008


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Pages 11 through 25 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4

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Wayne ARC - Combined Redacted-Bates HW

Documents