ufcw cent ohio - redacted hwm

7/27/2019 UFCW Cent Ohio - Redacted HWM

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///co-adshare/...20and%20Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Waiver%20application.htm[11/15/2011 2:10:

rom: William H. Tobin [[email protected]]ent: Tuesday, November 30, 2010 6:40 PM

To: HHS HealthInsurance (HHS); OCIIO Oversightubject: Waiver application

Attachments: waiver application.pdf

Dear Sir or Madam:

On behalf of the the UFCW Unions' and Employers' Health and Welfare Plan of Central Ohio

the "Plan"), I attach correspondence and supporting documentation regarding the Plan's application fo

waiver from restricted annual limits.

lease review the attached and respond at your earliest convenience. My e-mail address is

[email protected], and my direct phone number is 414-298-8279.

t is my understanding that the email inbox [email protected] may be full, and therefore I

ending to both that email address [email protected] in order to ensure receipt.

Thank you for your attention to this matter.

William H. Tobin

einhart Boerner Van Deuren s.c.

000 North Water Street, Suite 1700 | Milwaukee, WI 53202

ffice: 414-298-8279 | Fax: 414-298-8097

[email protected] | bio | vCard | reinhartlaw.com

UFCW COH:000001
mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/http://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinmailto:[email protected]:[email protected]:[email protected]:[email protected]


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UFCW COH:000006


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UFCW COH:000007


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UFCW COH:000008


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UFCW COH:000009


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UFCW COH:000010


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UFCW COH:000011


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///co-adshare/...20and%20Welfare%20Plan%20of%20Central%20Ohio/Reqeust%20for%20info%20response%20(2)%2012.13.10.htm[11/15/2011 2:10:

rom: William H. Tobin [[email protected]]ent: Monday, December 13, 2010 4:47 PM

To: William H. Tobin; Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application - UFCW Unions' and Employers' Health and Welfare Plan of Central Ohio

Attachments: Central OH H&W Waiver Application & Exh A.PDF; Central OH H&W Annual Limit WaiverApplication (HHS spreadsheet).PDFDear Ms. Habit,

Attached please find the materials requested in your email below. Thank you for your consideration of the Plan'swaiver application.

lease contact me with any questions or comments.

ill Tobin

William H. Tobin



ffice: 414-298-8279 | Fax: 414-298-8097


rom: Habit, Sandra (HHS/OCIIO) [mailto:[email protected]]ent: Friday, December 10, 2010 10:51 AMo: William H. Tobinubject: Waiver Application - UFCW Unions' and Employers' Health and Welfare Plan of Central Ohio

Dear Mr. Tobin,

hank you for your waiver application on behalf of UFCW Unions and Employers' Health and Welfare Plan ofCentral Ohio.We would like to expedite processing your application and request that you provide the following

nformation to facilitate this:

Please complete the entire annual limits spreadsheet, attached to this email. Please return the completed

spreadsheet 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.

Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be

complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140?

You may wish to provide a statement explaining how compliance with the annual limits will result in a

decrease in access to benefits.

What is the date on which the last collective bargaining agreement pursuant to which the plan was

negotiated will expire?

n order to complete your application, please provide this information by 5:00 pm, December 13, 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

Kind regards,andy

UFCW COH:000021
mailto:[email protected]://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/http://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinmailto:[email protected]


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///co-adshare/...20and%20Welfare%20Plan%20of%20Central%20Ohio/Reqeust%20for%20info%20response%20(2)%2012.13.10.htm[11/15/2011 2:10:

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

[email protected]

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e

f the law.

UFCW COH:000022
mailto:[email protected]:[email protected]


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UFCW COH:000023


24/68

UFCW COH:000024


25/68

UFCW COH:000025


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UFCW COH:000027


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UFCW COH:000028


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///co-adshare/...ployers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Reqeust%20for%20info%20response.htm[11/15/2011 2:10:

rom: William H. Tobin [[email protected]]ent: Monday, December 13, 2010 4:45 PM

To: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application - UFCW Unions' and Employers' Health and Welfare Plan of Central Ohio

Attachments: Central OH H&W Waiver Application & Exh A.PDF; Central OH H&W Annual Limit WaiverApplication (HHS spreadsheet).PDF


Dear Mr. Tobin,

hank you for your waiver application on behalf of UFCW Unions and Employers' Health and Welfare Plan ofCentral Ohio.We would like to expedite processing your application and request that you provide the followingnformation to facilitate this:




complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140?

You may wish to provide a statement explaining how compliance with the annual limits will result in a





Kind regards,andy

andy Habitepartment of Health and Human Services


01-492-4175

[email protected]



UFCW COH:000029


30/68

///co-adshare/...ployers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Reqeust%20for%20info%20response.htm[11/15/2011 2:10:


f the law.

UFCW COH:000030


31/68

///co-adshare/...Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Request%20for%20info%20response%2012.16.10.htm[11/15/2011 2:10

rom: Maire Mills Greenya [[email protected]]ent: Thursday, December 16, 2010 11:03 AM

To: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application Spreadsheet (Excel) - UFCW Unions' and Employers' Health and Welfare Plan of

Central Ohio

mportance: High

Attachments: 021001_ HHS excel waiver application (12_10).XLS.XLSDear Ms. Habit:

ursuant to your request, I attach the Waiver Application for the UFCW Unions' and Employers' Health

nd Welfare Plan of Central Ohio in Excel (instead of .pdf format), which was originally submitted to yo

n December 13, 2010.

f you have any questions or comments, please do not hesitate to contact Bill Tobin at 414-298-8279 and/

[email protected].

incerely,

Maire Mills Greenya,ssistant to William H. Tobin



ffice: 414-298-8454 | Fax: 414-298-8097

[email protected] | reinhartlaw.com

rom: William H. Tobinent: Monday, December 13, 2010 3:47 PMo: William H. Tobin; 'Habit, Sandra (HHS/OCIIO)'ubject: RE: Waiver Application - UFCW Unions' and Employers' Health and Welfare Plan of Central Ohio

Dear Ms. Habit,

Attached please find the materials requested in your email below. Thank you for your consideration of the Plan'swaiver application.

lease contact me with any questions or comments.

ill Tobin

William H. Tobineinhart Boerner Van Deuren s.c.


ffice: 414-298-8279 | Fax: 414-298-8097

UFCW COH:000031
mailto:[email protected]:[email protected]:[email protected]://reinhartlaw.com/http://reinhartlaw.com/http://reinhartlaw.com/mailto:[email protected]:[email protected]


32/68




Dear Mr. Tobin,

hank you for your waiver application on behalf of UFCW Unions and Employers' Health and Welfare Plan ofCentral Ohio.We would like to expedite processing your application and request that you provide the followingnformation to facilitate this:




complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? You may wish to provide a statement explaining how compliance with the annual limits will result in a





Kind regards,andy

andy Habit



01-492-4175

[email protected]




f the law.

ny advice expressed in this writing as to tax matters was neither written nor intended by the sender or Reinhart Boerner Van

euren s.c. to be used and cannot be used by any taxpayer for the purpose of avoiding tax penalties that may be imposed on

UFCW COH:000032
mailto:[email protected]://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/mailto:[email protected]:[email protected]://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinmailto:[email protected]


33/68


axpayer. If any such tax advice is made to any person or party other than to our client to whom the advice is directed and

tended, then the advice expressed is being delivered to support the promotion or marketing (by a person other than Reinhart

oerner Van Deuren s.c.) of the transaction or matter discussed or referenced. Each taxpayer should seek advice based on the

axpayer's particular circumstances from an independent tax advisor.

his e-mail and any attachments may contain privileged or confidential information. This e-mail is intended solely for the use of

dividual or entity to which it is addressed. If you are not the intended recipient of this e-mail, you are hereby notified that any

opying, distribution, dissemination or action taken in relation to the contents of this e-mail and any of its attachments is strictly

rohibited and may be unlawful. If you have received this e-mail in error, please notify the sender immediately and permanentelete the original e-mail and destroy any copies or printouts of this e-mail as well as any attachments. To the extent

epresentations are made herein concerning matters of a client of the firm, be advised that such representations are not those o

he client and do not purport to bind them.

UFCW COH:000033


34/68

///co-adshare/...0and%20Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Completion%2012.20.10.htm[11/15/2011 2:10

rom: Habit, Sandra (HHS/OCIIO)ent: Monday, December 20, 2010 11:10 AM

To: '[email protected]'ubject: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

December 20, 2010

Mr. Tobin

hank you for your information.

Your application is now complete and you will receive a determination of your application within 30 days. Take cnd have a happy holiday!

hank you,andy

andy Habit


ffice of Consumer Information and Insurance Oversight01-492-4175

[email protected]




f the law.

UFCW COH:000034


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///co-adshare/...rs'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Additional%20info%20needed%2012.22.10.htm[11/15/2011 2:10

rom: Pham, Erica (HHS/OCIIO)ent: Wednesday, December 22, 2010 7:09 PM

To: Habit, Sandra (HHS/OCIIO)Cc: Curtis, Barbara (HHS/OCIIO)ubject: UFCW Unions' & Ers' Health & Welfare Plan of Central Ohioi Sandy:

We reviewed the plan below. Can you please communicate to them that we need more information, otherwise we will deny the

pplication? Unfortunately, the rational is insufficient, and unless they provide more information/specifics in regards to the

ecrease in access to benefits (the rise in costs would unexpectedly deplete plan assets and reserves). Please resubmit toarbara if and when they provide more information.

hanks!

rica

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 51B

(part-time)

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 53A

(part-time)

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

UFCW COH:000035


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///co-adshare/...rs'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Additional%20info%20needed%2012.22.10.htm[11/15/2011 2:10

082

Central

Ohio

Plan 55A

(part-time)

082

UFCWUnions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 57A

(part-time)

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 61

(part-time)

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 20

(retiree)

rica Pham

ivision of Enforcement

ffice of Oversight

CIIO/HHS

01-492-4108

[email protected]

UFCW COH:000036


37/68

///co-adshare/...%20and%20Welfare%20Plan%20of%20Central%20Ohio/Additional%20info%20needed%20response%2012.23.10.htm[11/15/2011 2:10

rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 23, 2010 12:17 PM

To: Pham, Erica (HHS/OCIIO); Curtis, Barbara (HHS/OCIIO)ubject: RE: UFCW Unions' & Ers' Health & Welfare Plan of Central Ohio

Attachments: Central OH HW Waiver Application Exh A (2).pdfdditional information can be found on pages 1-5 of the attached document. I will see if this is something we can put in front o

teve next week.

hanks,andy

rom: Pham, Erica (HHS/OCIIO)ent: Wednesday, December 22, 2010 7:09 PMo: Habit, Sandra (HHS/OCIIO)c: Curtis, Barbara (HHS/OCIIO)ubject: UFCW Unions' & Ers' Health & Welfare Plan of Central Ohio

i Sandy:

We reviewed the plan below. Can you please communicate to them that we need more information, otherwise we will deny the

pplication? Unfortunately, the rational is insufficient, and unless they provide more information/specifics in regards to the

ecrease in access to benefits (the rise in costs would unexpectedly deplete plan assets and reserves). Please resubmit to

arbara if and when they provide more information.

hanks!

rica

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 51B

(part-time)

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central Plan 53A

UFCW COH:000037


38/68


082 Ohio (part-time)

082

UFCW

Unions' &Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 55A

(part-time)

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 57A

(part-time)

082

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central

Ohio

Plan 61

(part-time)

UFCW

Unions' &

Ers' Health

& Welfare

Plan of

Central Plan 20

UFCW COH:000038


39/68


082 Ohio (retiree)

rica Pham

ivision of Enforcement

ffice of Oversight

CIIO/HHS

01-492-4108

[email protected]

UFCW COH:000039


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///co-adshare/...s'%20and%20Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Question%201.11.11.htm[11/15/2011 2:10







his e-mail and any attachments may contain privileged or confidential information. This e-mail is intended solely for the use of dividual or entity to which it is addressed. If you are not the intended recipient of this e-mail, you are hereby notified that any


rohibited and may be unlawful. If you have received this e-mail in error, please notify the sender immediately and permanent

elete the original e-mail and destroy any copies or printouts of this e-mail as well as any attachments. To the extent



UFCW COH:000041


42/68

///co-adshare/...0Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Question%20response%201.12.11.htm[11/15/2011 2:1

rom: Habit, Sandra (HHS/OCIIO)ent: Wednesday, January 12, 2011 6:13 PM

To: 'William H. Tobin'ubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohioill,

apologize for the delay. I sent your application for leadership review. I will get a response for you expedited.

hank you,

andy

rom: William H. Tobin [mailto:[email protected]]ent: Tuesday, January 11, 2011 10:08 AMo: Habit, Sandra (HHS/OCIIO)c: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

andra,ust wanted to follow-up on this and see if you had any questions. I realize it has not been 30 days sinceour 12/20/2010 email, but we originally submitted the application on 11/30/2010 and responded to the 12/10/2010

equest for the spreadsheet on 12/13/2010.hanks for your assistance.ill Tobin

William H. Tobin



ffice: 414-298-8279 | Fax: 414-298-8097


rom: Habit, Sandra (HHS/OCIIO) [mailto:[email protected]]ent: Monday, December 20, 2010 10:10 AMo: William H. Tobinubject: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

December 20, 2010

Mr. Tobin



hank you,andy

andy Habit



UFCW COH:000042


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///co-adshare/...lth%20and%20Welfare%20Plan%20of%20Central%20Ohio/Question%20response%20correspondence%201.12.11.htm[11/15/2011 2:10

rom: William H. Tobin [[email protected]]ent: Wednesday, January 12, 2011 7:01 PM

To: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohiohanks very much.ill

rom: Habit, Sandra (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, January 12, 2011 5:13 PMo: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

ill,


hank you,

andy

rom: William H. Tobin [mailto:[email protected]]ent: Tuesday, January 11, 2011 10:08 AMo: Habit, Sandra (HHS/OCIIO)c: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

andra,ust wanted to follow-up on this and see if you had any questions. I realize it has not been 30 days sinceour 12/20/2010 email, but we originally submitted the application on 11/30/2010 and responded to the 12/10/2010equest for the spreadsheet on 12/13/2010.hanks for your assistance.ill Tobin

William H. Tobin



ffice: 414-298-8279 | Fax: 414-298-8097


rom: Habit, Sandra (HHS/OCIIO) [mailto:[email protected]]ent: Monday, December 20, 2010 10:10 AM

o: William H. Tobinubject: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

December 20, 2010

Mr. Tobin



UFCW COH:000044


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///co-adshare/...lth%20and%20Welfare%20Plan%20of%20Central%20Ohio/Question%20response%20correspondence%201.12.11.htm[11/15/2011 2:10

hank you,andy

andy Habit



[email protected]




f the law.










rohibited and may be unlawful. If you have received this e-mail in error, please notify the sender immediately and permanentelete the original e-mail and destroy any copies or printouts of this e-mail as well as any attachments. To the extent



UFCW COH:000045


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App li cant

ID

Number

Annual Limit Waiver

Request Applicant

Name

Name

(use a

new row

for each

policy

applicatio

n)

Appli cant

(Plan/

Policy

Situs)

City

App li cant

(Plan/

Policy

Situs)

State

Plan/

Policy

Effective

Date

(mm/dd/yy

yy)

Contact

Name

Street

Address City State

082

UFCW Unions' &

Workers' Health &

Welfare Plan o f

Central OhioPlan 51A

(part-time) Columbus OH 01/01/2011

William

Tobin

1000 N.

Water St.,

Ste. 1700

Milwauke

e WI

UFCW Unions' &

Workers' Health &

Welfare Plan o f

Central OhioPlan 51B


William

Tobin

1000 N.

Water St.,

Ste. 1700

Milwauke

e WI

UFCW Unions' &

Workers' Health &

Welfare Plan of Plan 53A William1000 N.

Water St. Milwauke

Central Ohio


Tobin

Ste. 1700 e WI

UFCW Unions' &

Workers' Health &

Welfare Plan o f



William

Tobin

1000 N.

Water St.,

Ste. 1700

Milwauke

e WI


47/68

Coverage

(e.g.,

Limited

Benefit,

HRA, Rx

only,

Other)

Self-

Insured

Individual

or Group

Policy

Number

of

Individual

s

Covered

by Policy

(include

Current

Plan

Annual

Limit (in

dollars)

Ambulato

ry

Emergen

cy

Hospitali

zation

Laborator

y Pediatric

Maternity

/

Newborn

Limited

Benefit Yes Group

Limited

Benefit Yes Group

Limited

Benefit Yes Group

Limited

Benefit Yes Group


48/68

Prescripti

on

Plan

Deductibl

e

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Individual

/

Employe

e Tier*


49/68


50/68

Plan

Adminis trat

or/ CEO of

Health

Insurance

Issuer

Name

Title of

Individual

Providing

Attestation

Taft-Hartley

Plan

If Yes Taft-

Hartley then

Date Collecti ve

Bargaining

Agreement

Expires

Compliance

with

Grandfather

Regulat ion Lead Reviewer

Date of

Receipt

Board of

Trustees Trustee Yes 03/01/2014 Yes S. Habit 12/01/2010

Board of


Boardof


Board of



51/68

Factor 1 for

Decision

Factor 2

for

Decision

Factor 3

for

Decision

Factor 4

for

Decision

Staff

Recomm

endation

for

Approval/

Disappro

val Comments

1: A significant

decrease in

access to

benefits. Approve

Increase in annual deductible to $ from $ . Due to theTrustees' inability to increase contributions during the terms

of existing collective bargaining agreementsthe Trustees'

would be required to consider various benefits changes

which would be expected to result in a decrease in access to

benefits.

1: A significant

decrease in

access to

benefits. Approve

.

Trustees' inability to increase contributions during the terms




benefits

1: A significant

decrease in

access to

An increase in deductible to from . Due to the

Trustees' inability to increase contributions during the terms



which wouldbe ex ected to resultina decrease inaccess to

benefits. Approve

benefits

1: A significant

decrease in

access to

benefits. Approve

Increase in annual deductible to $ from $ . Due to theTrustees' inability to increase contributions during the terms




benefits


52/68

Final

Decision

Decision

Date

Date of

Waiver

Approval/

Disappro

val Letter

Sent Y/N

Date of

Letter

Confirma

tion of

Receipt

of

Approval

Access

File


53/68

App li cant

ID

Number

Annual Limit Waiver

Request Applicant

Name

Name

(use a

new row

for each

policy

applicatio

n)

Appli cant

(Plan/

Policy

Situs)

City

App li cant

(Plan/

Policy

Situs)

State

Plan/

Policy

Effective

Date

(mm/dd/yy

yy)

Contact

Name

Street

Address City State

UFCW Unions' &

Workers' Health &

Welfare Plan o f



William

Tobin

1000 N.

Water St.,

Ste. 1700

Milwauke

e WI

UFCW Unions' &

Workers' Health &

Welfare Plan o f

Central Ohio

Plan 61


William

Tobin

1000 N.

Water St.,

Ste. 1700

Milwauke

e WI

UFCW Unions' &

Workers' Health &

Welfare Plan o f

Central OhioPlan 20

(retiree) Columbus OH 01/01/2011

William

Tobin

1000 N.

Water St.,

Ste. 1700

Milwauke

e WI


54/68

Coverage

(e.g.,

Limited

Benefit,

HRA, Rx

only,

Other)

Self-

Insured

Individual

or Group

Policy

Number

of

Individual

s

Covered

by Policy

(include

Current

Plan

Annual

Limit (in

dollars)

Ambulato

ry

Emergen

cy

Hospitali

zation

Laborator

y Pediatric

Maternity

/

Newborn

Limited

Benefit Yes Group

Limited

Benefit Yes Group

Limited

Benefit Yes Group


55/68

Prescripti

on

Plan

Deductibl

e

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Copay (if

applicabl

e)

Coinsura

nce (if

applicabl

e)

Individual

/

Employe

e Tier*


56/68

Employe

e

contributi

on

Employer

contributi

on Total

Employe

e

contributi

on

Employer

contributi

on Total

Rate Increase

that would

result from

compliance

with $750,000

Annual Limi t

Restriction (in

Decrease in Access to Benefits that w

compliance with $750,000 Annual Lim

briefly)

"The Trustees have concluded that incr

maximum to $750,000 per year for t

J anuary 1, 2011 for all benefit program

significantly, as calculated by the plan's

costs would unexpectedly deplete pla


maximum to $750,000 per year for t





maximumto 750 000 er ear for th





57/68

Plan

Adminis trat

or/ CEO of

Health

Insurance

Issuer

Name

Title of

Individual

Providing

Attestation

Taft-Hartley

Plan

If Yes Taft-

Hartley then

Date Collecti ve

Bargaining

Agreement

Expires

Compliance

with

Grandfather

Regulat ion Lead Reviewer

Date of

Receipt

Board of


Board of


Board of



58/68

Factor 1 for

Decision

Factor 2

for

Decision

Factor 3

for

Decision

Factor 4

for

Decision

Staff

Recomm

endation

for

Approval/

Disappro

val Comments

Deny

Increase deductible to $ from $ . Due to the Trusteesinability to increase contributions during the terms of existing

collective bargaining agreementsthe Trustees' would be

required to consider various benefits changes which would

be expected to result in a decrease in access to benefits

6: The number of

enrollees under

the plan seeking

the waiver.

1: A

significant

decrease

in access

to

benefits. Approve

Increase deductible to $ from $ . Due to the Trusteesinability to increase contributions during the terms of existing

collective bargaining agreementsthe Trustees' would be

required to consider various benefits changes which would

be expected to result in a decrease in access to benefits.

1: A

significant

decrease

Increase deductible to $ from $ . Due to theTrustees' inability to increase contributions during the terms

ofexistin collective bar ainin a reementsthe Trustees'

2: The policy's

current annual

limits.

in access

to

benefits. Approve



benefits


59/68

Final

Decision

Decision

Date

Date of

Waiver

Approval/

Disappro

val Letter

Sent Y/N

Date of

Letter

Confirma

tion of

Receipt

of

Approval

Access

File


60/68

///co-adshare/...%20Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Status%20request%201.21.11.htm[11/15/2011 2:10

rom: William H. Tobin [[email protected]]ent: Friday, January 21, 2011 12:51 PM

To: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohioandra,

Any further word? If there is some additional information that would be helpful please let me know and I will do wcan to get it to you as soon as possible. Thanks again for your consideration.ill

William H. Tobin



ffice: 414-298-8279 | Fax: 414-298-8097


rom: Habit, Sandra (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, January 12, 2011 5:13 PMo: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

ill,


hank you,

andy

rom: William H. Tobin [mailto:[email protected]]ent: Tuesday, January 11, 2011 10:08 AMo: Habit, Sandra (HHS/OCIIO)

c: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio


William H. Tobin


000 North Water Street, Suite 1700 | Milwaukee, WI 53202ffice: 414-298-8279 | Fax: 414-298-8097



UFCW COH:000060
mailto:[email protected]://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/mailto:[email protected]://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/http://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinmailto:[email protected]://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinmailto:[email protected]


61/68

///co-adshare/...%20Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Status%20request%201.21.11.htm[11/15/2011 2:10

December 20, 2010

Mr. Tobin



hank you,andy

andy Habit



01-492-4175

[email protected]




f the law.




tended, then the advice expressed is being delivered to support the promotion or marketing (by a person other than Reinhartoerner Van Deuren s.c.) of the transaction or matter discussed or referenced. Each taxpayer should seek advice based on the









UFCW COH:000061


62/68

///co-adshare/...ers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Status%20request%20response%201.21.11.htm[11/15/2011 2:10

rom: Habit, Sandra (HHS/OCIIO)ent: Friday, January 21, 2011 2:29 PM

To: 'William H. Tobin'ubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohioill,

he application for UFCW Unions and Employers Health and Welfare Plan of Central Ohio made it to leadership but unfortunat

more information was requested. To the best of my knowledge, the application will again go to leadership next week and as I

ttend those meetings I will be able to contact you with an answer once I know either way. Thank you for you patience in this

matter.

andy

rom: William H. Tobin [mailto:[email protected]]ent: Friday, January 21, 2011 12:51 PMo: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

andra,Any further word? If there is some additional information that would be helpful please let me know and I will do w

can to get it to you as soon as possible. Thanks again for your consideration.illWilliam H. Tobin



ffice: 414-298-8279 | Fax: 414-298-8097


rom: Habit, Sandra (HHS/OCIIO) [mailto:[email protected]]

ent: Wednesday, January 12, 2011 5:13 PMo: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio

ill,


hank you,

andy

rom: William H. Tobin [mailto:[email protected]]

ent: Tuesday, January 11, 2011 10:08 AMo: Habit, Sandra (HHS/OCIIO)c: William H. Tobinubject: RE: Waiver Application - UFCW Unions and Employers Health and Welfare Plan of Central Ohio


UFCW COH:000062


63/68


William H. Tobin



ffice: 414-298-8279 | Fax: 414-298-8097



December 20, 2010

Mr. Tobin



hank you,andy

andy Habit



01-492-4175

[email protected]




f the law.

ny advice expressed in this writing as to tax matters was neither written nor intended by the sender or Reinhart Boerner Vaneuren s.c. to be used and cannot be used by any taxpayer for the purpose of avoiding tax penalties that may be imposed on








UFCW COH:000063
mailto:[email protected]:[email protected]://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/mailto:[email protected]:[email protected]://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinmailto:[email protected]


64/68






UFCW COH:000064


65/68

///co-adshare/...'%20and%20Employers'%20Health%20and%20Welfare%20Plan%20of%20Central%20Ohio/Approval%201.31.11.htm[11/15/2011 2:10

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Monday, January 31, 2011 12:22 PM

To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: UFCW Unions' & Workers' Health & Welfare Plan of Central Ohio Waiver of the Annual Limits

Requirements 1-31-2011

mportance: High

Attachments: January 1 Approval Letter .pdf

ood Morning,

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

ection 2711 forUFCW Unions' & Workers' Health & Welfare Plan of Central Ohio. HHS has reviewed yourpplication and made its determination. Please see the attached letter.

he attached letter refers to the following plans:

Plan 51A

(part-time)

Plan 51B

(part-time)

Plan 53A

(part-time)

UFCW COH:000065


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67/68

UFCW COH:000067


68/68

ufcw cent ohio - redacted hwm

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