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///co-adshare/...-%20Torres/DFOI%20Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Waiver.txt[11/15/2011 11:37:

rom: Andrea D Goldberger [[email protected]]ent: Tuesday, November 30, 2010 5:04 PMo: OCIIO Oversight; HHS HealthInsurance (HHS)

Cc: 'Sarah E. Sanchez'; 'Barry S. Slevin'; 'Sharon M. Goodman';Gingell, John'ubject: Waiver

Attachments: Waiver Application.pdf

Good Afternoon,

Attached please find an Application for Waiver of PPACA Lifetime Limits Prohibition filed on behalf of the UFCWocal One Health Care Fund.

hank you,

Andrea D. GoldbergerUFCW Local One Benefit Funds911 Airport Road

Oriskany, NY 13424

15-797-9600, ext 2253ax: 315-797-9664

UFCW L ONE:000001


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///co-adshare/...I%20Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Waiver%20and%20SPD.txt[11/15/2011 11:37:

rom: Andrea D Goldberger [[email protected]]ent: Wednesday, December 01, 2010 12:58 PMo: OCIIO Oversight; HHS HealthInsurance (HHS)

Cc: 'Sarah E. Sanchez'; 'Barry S. Slevin'; 'Sharon M. Goodman'; 'Gingell, John'ubject: Waiver and SPD

Attachments: Waiver Application.pdf; hc spd - 2009 8x11_FINAL.pdf; WRAPPLAN009.pdf; PLAN Q PPO 2009.pdf; PLAN R PPO-2009.pdf; PLAN S PPO - 1-1-010.pdf; PLAN T PPO.pdf; PLAN U PPO 8-1-2010.pdf

Good Afternoon,

Attached please find an Application for Waiver of PPACA Lifetime Limitsrohibition filed on behalf of the UFCW Local One Health Care Fund, as well ascopy of the Fund's SPD and Plan Summaries. The Application was emailedesterday, November 30th; however, the SPD and Summaries were inadvertentlyeft off the email.

hank you,

Andrea D. Goldberger

UFCW Local One Benefit Funds911 Airport Road

Oriskany, NY 1342415-797-9600, ext 2253ax: 315-797-9664

UFCW L ONE:000002


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UFCW L ONE:000003


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UFCW L ONE:000004


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UFCW L ONE:000005


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Mr. JamesMayhewPage

agreement xpiresand s renegotiatedandeven henmay decidenot to increasecontributions.)Thus, he Fund's only option for addressinghe increased ostsinvolved in eliminating the lifetime limits describedabove likely is tosignificantly educe hese enefits r otherbenefits fferedby theFund.If theDepartment f HealthandHumanServiceswill notgrant heFunda waiverof the ifetime imits described erein,but wouldgranta waiver or such imits ifthey arefirst convertedo annual imits, the Boardof Trusteeswill amend hePlan o convert hereferencedifetime imits to annualimits, effectiveJanuary1,2011,andhereby eeks waiverof suchannualimits.

6. The requiredattestation f the informationabove,signedby the ChairmanandCo-Chairman f the Fund's Board of Trustees,s enclosed s AttachmentA tothis etter.We respectfully equestexpeditedhandlingof this matter. If you have anyquestions r needadditionalnformation, lease ontactheundersigned.

Sincerely,l \ . -ftft/^r- D Arurv\


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ArrncnmENTAUFCW Locu, Oun Hn.lr,rn Canr FuNoPPACALrnnrlnnnLTNNNSrVNN APPLICATIONAttnsr,luoN oFPr,.q,NtvrrNIstn lroR

On behalf of the Boardof Trustees f the UFCW Local One HealthCareFund(ooFund"),the undersigned,Chairmanand Co-Chairmanof the UFCW Local One Health Care Fund, doherebyattest o the following:

(1) heFundwas n forceprior o September3,2010;and(2) basedupon the information contained n the Fund's letter to which this Attestation isattachedas Exhibit A ("Letter"), the elimination of the lifetime limits referenced n theLetter, and the application of restricted annual limits to the benefits referenced n theLetter, would result in a significant decrease n access o benefits for those currentlycoveredby the Plan and/or a significant increase n the amountsneeded o cover the costof the Plan.

One Health Care Plan

315260v1

I One Health Care Plan

UFCW L ONE:000007


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///co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.17.10.htm[11/15/2011 11:37

rom: Keels, Lisa (HHS/OCIIO)ent: Friday, December 17, 2010 2:53 PM

To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Attachments: Waiver Application Form.xlsxDear Andrea:

hank you for speaking with me today and for your application for the Waiver of the Annual Limits Requirements he Public Health Service Act (PHS Act) Section 2711. In order to expedite your application, please provide theollowing information:

I. Please complete the entire annual limits spreadsheet, which is attached to this email. Please return thecompleted spreadsheet to this email address as an attachment. We will only be able to process spreadshthat are fully complete (i.e., every cell should contain the information requested). If a cell on thespreadsheet does not pertain to your plan, please write None, and/or provide an explanation regardingwhy you are unable to complete that particular cell in a separate document.

II. In addition, please provide the following information:

As we discussed, please confirm that, pending a waiver, you plan to convert the $ lifetime limit onretirees and their spouses to an annual limit, and that you are applying for a waiver on the $ annual limon retirees and their spouses.

As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential heal

benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not beissued regarding this matter, we rely on the Interim Final Regulations, which state that, [f]or plan years . .beginning before the issuance of regulations defining essential health benefits, for purposes of enforcemen

the Departments will take into account good faith efforts to comply with a reasonable interpretation of the t

essential health benefits. (Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Do

believe in good faith that hearing aids are not considered essential health benefits? If so, please confirm tyou are not applying for a waiver on the hearing aid limits.

Also as we discussed, please confirm that you are not applying for a waiver on adult orthodontic, optical, an

dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extenyou have them.

Please 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?

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

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

n order to complete your application, please provide this information by 5:00pm, December 20, 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,isa

UFCW L ONE:000009


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rom: Andrews, Jane (HHS/OCIIO)ent: Monday, December 20, 2010 10:20 AM

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

ubject: Your application for a waiver of annual limiits

Attachments: Waiver Application Form.xlshank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act

PHS Act) 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 spreadshto this email address as an attachment. We will only be able to process spreadsheets that are fully comp(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain tyour plan, please write None, and/or provide an explanation regarding why you are unable to completethat particular cell in a separate document.

II. In addition, if you did not include the following information in your application and is applicable, pleaseprovide 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.

Confirm whether the plan was created pursuant to the Taft-Hartley Act. If it is, please provide the date the

collective bargaining agreement will expire.

Confirm that your plan is either self-insured or fully insured.

If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance,

please submit that with the spreadsheet as a separate attachment.

n order to complete your application, please provide this information by 5:00 pm, December 22, 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 and feel free to contact me with questions.

ane W. Andrews

CIIO

501 Wisconsin Aveethesda, MD 20814

01-492-4122 (desk)

02-536-6779 (Blackberry)

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

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

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

UFCW L ONE:000011


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///co-adshare/...ocal%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20correspondence%2012.20.10.htm[11/15/2011 11:37

rom: Keels, Lisa (HHS/OCIIO)ent: Monday, December 20, 2010 10:59 AM

To: Sarah E. SanchezCc: [email protected]; Price, Francoise; Gingell, John; Sharon M. Goodman; Habit, SandraHHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Ms. Sanchez,

hank you for your email and for letting me know about the Funds schedule. HHS will process your application auickly as possible after it is completed. However, please note that, as stated in our September 3, 2010 Guidance,HHS will issue a decision within 30 days of receiving a complete application.

lease feel free to contact me with any questions.

hank you again,isa

isa M. Keels, J.D.U.S. Department of Health & Human ServicesOffice of Consumer Information and Insurance Oversight

Office of [email protected]

rom: Sarah E. Sanchez [mailto:[email protected]]ent: Monday, December 20, 2010 10:44 AMo: Keels, Lisa (HHS/OCIIO)c: [email protected]; Price, Francoise; Gingell, John; Sharon M. Goodmanubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Ms. Keels-

his firm represents the UFCW Local One Health Care Fund. This is in response to your below email to the Fund Director, An

oldberger. The Fund is in the process of putting together the data necessary to respond to your request for additional

formation. However, it is unlikely that the Fund will be able to respond by 5pm today. The Fund will make every attempt to

rovide you with the requested information by Thursday of this week. Please let me know if that presents any problem. Thank

arah Sanchez

arah E. Sanchez

rincipal

levin & Hart, P.C.

625 Massachusetts Ave., N.W., Suite 450

Washington, D.C. 20036

02-797-8700 Tel02-234-8231 Fax

[email protected]

RS CIRCULAR 230 NOTICE: To comply with requirements imposed by the IRS, this is to inform you that any tax advice contained in this

ommunication (including any attachments) was not intended or written to be used, and cannot be used, for the purpose of (i) avoiding tax-re

enalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any matter addressed herein.

he information contained in this message is intended only for the use of the designated recipients named above. This message may be an

ttorney-client communication, and as such, is privileged and confidential If the reader of this message is not the intended recipient or an ag

esponsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error, and that any revie

issemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please notify

UFCW L ONE:000012
mailto:[email protected]:[email protected]


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As we discussed, please confirm that, pending a waiver, you plan to convert the $ lifetime limit on retirnd their spouses to an annual limit, and that you are applying for a waiver on the $ annual limit on retirees aheir spouses.

As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential healtenefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issu

egarding this matter, we rely on the Interim Final Regulations, which state that, "[f]or plan years . . . beginning befhe issuance of regulations defining 'essential health benefits,' for purposes of enforcement, the Departments will tanto account good faith efforts to comply with a reasonable interpretation of the term 'essential health benefits.'"Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Do you believe in good faith that heariids are not considered "essential health benefits?" If so, please confirm that you are not applying for a waiver on earing aid limits.

Also as we discussed, please confirm that you are not applying for a waiver on adult orthodontic, optical, andental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you h

hem.

Please confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance wrandfathering provisions, pursuant to 45 CFR 147.140?




hank you,isa

isa M. Keels, J.D.U.S. Department of Health & Human ServicesOffice of Consumer Information and Insurance OversightOffice of Oversight

[email protected]

UFCW L ONE:000014


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UFCW L ONE:000015


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ANNUAL LIMIT WAIVER APPLICATIO

Annual L imit

Waiver

Request

Appl icant

Name

Policy Name

(use a new

row for each

policy

application)

Appl icant

(Plan/ Policy

Situs) City

Appl icant

(Plan/

Policy

Situs)

State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City State Zip Code

Phone

Number

(including

area code)

Ema

Addr

UFCW LocalOne HealthCare Fund Plan M Oriskany NY 01/01/2011

AndreaGoldberger

5911 AirportRd Oriskany NY 13424

1-315-797-9600, ext

2253

andberg

n

UFCW LocalOne HealthCare Fund Retiree Oriskany NY 01/01/2011

AndreaGoldberger

5911 AirportRd Oriskany NY 13424

1-315-797-9600, ext

2253

andberg

n

PRA Disclosure Statement


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Emergency Hospitalization Laboratory Pediatric

Maternity/

Newborn

Mental Health/

Substance

Abuse

Rehabilitative/

Devices

Preventive/

Wellness Pres

Current Essential Benefits Annual Limits (Annual Limit for Each Essential Benefit)


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Coinsuran

ce (if

applicable)

Individual/ Employee

Tier*

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Em

cont

(if ap

$0.00 $0.00

$0.00 $0.00

Projected Rate Incr

from compliance with

Restriction (in dollar

Indi

Current Monthly Premium Rates or Premium

Equivalent Rates (in dollars)*:

x

insurance

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver Granted

(in dollars)*

Employee

Individual

* When completing the columns requesting premium rate information, please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee, Employee +Spouse, Employee +as a licable. If ou are an issuer, lease rovide the remium amount in the column titled, "Total" (Column AN,

* When completing the columns requesting premium rate information, please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee, Employee +Spouse, Employee +as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN,


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rom: Keels, Lisa (HHS/OCIIO)ent: Thursday, December 23, 2010 3:24 PM

To: [email protected]: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon MGoodman'ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Informationhank you, Andrea. I do have a couple of questions about the spreadsheet, and I just left you a voicemail message regardi

his:

1. I was wondering whether you are only applying for a waiver for the Funds Retiree coverage and Plan M. I know

those are the only two applications listed on the spreadsheet, but your original application provides SPDs for othe

plans. Some of these plans have lifetime limits of $ . Please confirm that you are either removing theselifetime limits or converting them to annual limits (which do not require a waiver this year because the limit would

above $750,000).

2. Also, for Plan M, the annual limit is listed as $ on the spreadsheet. I assume that there is no overall annual land that the $ is the limit on preventive care, as is stated in your original application. Please confirm whethethis is the case, and I will change the spreadsheet to reflect this.

3. Is Plan M the Mini-Wrap Plan included in your original application? I notice that that plan has a $ limit onpreventive care, so Im assuming they are the same. However, please confirm.

s I mentioned in my voicemail, I am out of the office now through next week. However, I will be checking my email

ntermittently, and I will respond to you as quickly as possible.

hank you again, and happy holidays.

sa

rom: Andrea D Goldberger [mailto:[email protected]]ent: Thursday, December 23, 2010 2:13 PMo: Keels, Lisa (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon M. Goodman'ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Ms. Keels,

This is in response to your below request for additional information concerning the annualmits waiver application of the UFCW Local One Health Care Fund ("Fund").

. The completed spreadsheet includes information pertaining to the Funds Retiree coverand Plan M, a supplemental benefit Plan that does not include hospitalization or major medoverage.

I. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1,011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefitsnder the Plan, so that the Fund may retain the current $ limit on retiree benefits, onow, on an annual basis.

n its waiver application, the Fund indicated that it intended to apply for a waiver relating tmits on the essential benefits available under the Plan. Per your request, this is to adviseou that the Fund has a good faith belief that the hearing aid benefit, the adult dental and

UFCW L ONE:000019


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ision benefits, and the orthodontic benefit are not essential benefits, as that term is used ihe PPACA, and therefore the Fund is not applying for an annual limits waiver relating to suenefits.

The Fund was in existence prior to March 23, 2010. It is the Fund's understanding that PlaQ, R and M meet the requirements of a "grandfathered plan," as that term is used in

pplicable regulations. These Plans are prepared to comply with the PPACA requirementspplicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund'snderstanding that Plans S, T and U will not be grandfathered, effective January 1, 2011.

These Plans are prepared to comply with the PPACA requirements applicable to non-randfathered plans, effective January 1, 2011.

Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Unioocal One and the Fund's various participating employers that call for contributions to theund. The effective and expiration dates of the current collective bargaining agreementsovering % of the Fund's participants are as follows:

4/6/2008-4/2/20114/27/2008-4/23/2011

/3/2008-7/30/2011

Should you have any questions, please contact the Fund office.

Thank you and Happy Holidays,

ndrea D. Goldberger

FCW Local One Benefit Funds

911 Airport Road

riskany, NY 13424

15-797-9600, ext 2253

ax: 315-797-9664

rom: Keels, Lisa (HHS/OCIIO) [mailto:[email protected]]ent: Friday, December 17, 2010 2:53 PMo: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Andrea:

hank you for speaking with me today and for your application for the Waiver of the Annual Limits Requirements he Public Health Service Act (PHS Act) Section 2711. In order to expedite your application, please provide the

ollowing information:



As we discussed, please confirm that, pending a waiver, you plan to convert the $ lifetime limit onUFCW L ONE:000020


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retirees and their spouses to an annual limit, and that you are applying for a waiver on the $ annual limon retirees and their spouses.


benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not beissued regarding this matter, we rely on the Interim Final Regulations, which state that, [f]or plan years . .beginning before the issuance of regulations defining essential health benefits, for purposes of enforcementhe Departments will take into account good faith efforts to comply with a reasonable interpretation of the tessential health benefits. (Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Do

believe in good faith that hearing aids are not considered essential health benefits? If so, please confirm tyou are not applying for a waiver on the hearing aid limits.








hank you,isa

sa M. Keels, J.D.

.S. Department of Health & Human Services

ffice of Consumer Information and Insurance Oversight

ffice of Oversight

[email protected]

01-492-4168

UFCW L ONE:000021


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///co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%2012.23.10.htm[11/15/2011 11:37

rom: Keels, Lisa (HHS/OCIIO)ent: Thursday, December 23, 2010 12:58 PM

To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Informationi Andrea,

hanks for your email. To answer your question, we are requesting the effective dates of each agreement, as well as the

ates each CBA expires. However, since you have 67 CBAs, at the moment, you can just provide the date the first CBAxpires.

We might ask for more information, but that is fine for now. Please let me know if this makes sense.

appy Holidays to you, too!

sa

rom: Andrea D Goldberger [mailto:[email protected]]

ent: Thursday, December 23, 2010 12:04 PMo: Keels, Lisa (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Lisa,

am forwarding our response to your request for information today and have a questionegarding the information you need pertaining to collective bargaining agreements. The unas 67 collective bargaining agreements that contain provisions for health care benefitshrough the UFCW Local One Health Care Fund. Are you requesting the effective dates of egreement or the earliest and more recent or something altogether different?

hank you and Happy Holidays!!

Andrea Goldberger

ndrea D. Goldberger


911 Airport Road

riskany, NY 13424

15-797-9600, ext 2253

ax: 315-797-9664


Dear Andrea:


UFCW L ONE:000022


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///co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%2012.23.10.htm[11/15/2011 11:37





benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not beissued regarding this matter, we rely on the Interim Final Regulations, which state that, [f]or plan years . .beginning before the issuance of regulations defining essential health benefits, for purposes of enforcementhe Departments will take into account good faith efforts to comply with a reasonable interpretation of the tessential health benefits. (Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Dobelieve in good faith that hearing aids are not considered essential health benefits? If so, please confirm t

you are not applying for a waiver on the hearing aid limits.








hank you,isa

sa M. Keels, J.D.



ffice of Oversight

[email protected]

01-492-4168

UFCW L ONE:000023


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///co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%2012.23.10.htm[11/15/2011 11:37:

rom: Andrea D Goldberger [[email protected]]ent: Thursday, December 23, 2010 2:13 PM

To: Keels, Lisa (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon MGoodman'ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Attachments: 5170 Waiver Application Spreadsheet from HHS w_Andrea_s Entries (UFCW 1) (1).XLSX

Dear Ms. Keels,This is in response to your below request for additional information concerning the annual

mits waiver application of the UFCW Local One Health Care Fund ("Fund").


I. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1,011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefitsnder the Plan, so that the Fund may retain the current $ limit on retiree benefits, onow, on an annual basis.n its waiver application, the Fund indicated that it intended to apply for a waiver relating tmits on the essential benefits available under the Plan. Per your request, this is to adviseou that the Fund has a good faith belief that the hearing aid benefit, the adult dental andision benefits, and the orthodontic benefit are not essential benefits, as that term is used ihe PPACA, and therefore the Fund is not applying for an annual limits waiver relating to suenefits.


pplicable regulations. These Plans are prepared to comply with the PPACA requirements

pplicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund'snderstanding that Plans S, T and U will not be grandfathered, effective January 1, 2011.These Plans are prepared to comply with the PPACA requirements applicable to non-

randfathered plans, effective January 1, 2011.

Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Unioocal One and the Fund's various participating employers that call for contributions to theund. The effective and expiration dates of the current collective bargaining agreementsovering % of the Fund's participants are as follows:

4/6/2008-4/2/20114/27/2008-4/23/2011

/3/2008-7/30/2011Should you have any questions, please contact the Fund office.


ndrea D. Goldberger


911 Airport Road

riskany, NY 13424

UFCW L ONE:000024


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15-797-9600, ext 2253

ax: 315-797-9664


Dear Andrea:




As we discussed, please confirm that, pending a waiver, you plan to convert the $ lifetime limit on retiand their spouses to an annual limit, and that you are applying for a waiver on the $ annual limit onretirees and their spouses.


benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not beissued regarding this matter, we rely on the Interim Final Regulations, which state that, [f]or plan years . .beginning before the issuance of regulations defining essential health benefits, for purposes of enforcemen

the Departments will take into account good faith efforts to comply with a reasonable interpretation of the tessential health benefits. (Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Dobelieve in good faith that hearing aids are not considered essential health benefits? If so, please confirm tyou are not applying for a waiver on the hearing aid limits.



Please confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance w





UFCW L ONE:000025


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hank you,isa

sa M. Keels, J.D.



ffice of Oversight

[email protected]

UFCW L ONE:000026


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///co-adshare/...0Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20clarification%2012.27.10.htm[11/15/2011 11:37:2

rom: Keels, Lisa (HHS/OCIIO)ent: Monday, December 27, 2010 7:57 AM

To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Informationi Andrea,

hope you are still enjoying the holiday season! Thanks so much for your clarifications below.

egarding the lifetime limits, I double checked, and the regulations state that lifetime limits need to be removed for all pla

eginning on or after September 23, 2010. ("the provisions of PHS Act section 2711, insofar as it relates to lifetime limits,...ap

o grandfathered health plans for plan years beginning on or after September 23, 2010." See 45 CFR 147.140(d)). In light of t

egulation, can you please confirm that you are either removing the lifetime limits or converting them to annual limits for all plan

both grandfathered and non-grandfathered)?

hank you again for your other responses and clarifications. Once you confirm that you are removing or converting the lifetime

mits, we will move forward with the application for Plan M (the mini-wrap plan) and the Funds Retiree coverage.

ave a great day,

sa

rom: Andrea D Goldberger [mailto:[email protected]]ent: Thursday, December 23, 2010 3:37 PMo: Keels, Lisa (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Hi Lisa sorry I missed your call! Regarding your questions, please see my comments belownitially, we included all plans with our application because the Plans have annual limits onrthodontia, dental, vision and hearing aids. Since at this time we do not believe that theseall under the definition of essential benefits, we did not include these Plans on thepreadsheet.

Our office is closed on Monday, however I will be working remotely and can be reached bymail or by cell at 518-857-9822.

Thank you, and Enjoy the Holiday!!

Andrea

ndrea D. Goldberger


911 Airport Road

riskany, NY 13424

15-797-9600, ext 2253ax: 315-797-9664

rom: Keels, Lisa (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 23, 2010 3:24 PMo: [email protected]: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon M. Goodman'ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

hank you, Andrea. I do have a couple of questions about the spreadsheet, and I just left you a voicemail message regardi

UFCW L ONE:000027


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his:

1. I was wondering whether you are only applying for a waiver for the Funds Retiree coverage and Plan M. I know

those are the only two applications listed on the spreadsheet, but your original application provides SPDs for othe

plans. Some of these plans have lifetime limits of $ Please confirm that you are either removing theselifetime limits or converting them to annual limits (which do not require a waiver this year because the limit would

above $750,000). The lifetime limits will be eliminated for all non-grandfathered plans effective 1/1/2011. The

lifetime limits for grandfathered plans will remain for Plan year 2011 as I believe that this is allowed.

2. Also, for Plan M, the annual limit is listed as $ on the spreadsheet. I assume that there is no overall annual land that the $ is the limit on preventive care, as is stated in your original application. Please confirm whethethis is the case, and I will change the spreadsheet to reflect this. Yes, you are correct. The $ is actually an annualimit on the amount paid for an annual physical. This Plan is a supplemental plan that has no hospitalization or ma

medical coverage, but encourages an annual physical.

3. Is Plan M the Mini-Wrap Plan included in your original application? I notice that that plan has a $ limit onpreventive care, so Im assuming they are the same. However, please confirm. Yes sorry! Mini-wrap and Plan M

one and the same!

s I mentioned in my voicemail, I am out of the office now through next week. However, I will be checking my email

ntermittently, and I will respond to you as quickly as possible.


sa

rom: Andrea D Goldberger [mailto:[email protected]]ent: Thursday, December 23, 2010 2:13 PMo: Keels, Lisa (HHS/OCIIO)

c: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon M. Goodman'ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Ms. Keels,

This is in response to your below request for additional information concerning the annualmits waiver application of the UFCW Local One Health Care Fund ("Fund").


I. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1,011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefitsnder the Plan, so that the Fund may retain the current $ limit on retiree benefits, onow, on an annual basis.

n its waiver application, the Fund indicated that it intended to apply for a waiver relating tmits on the essential benefits available under the Plan. Per your request, this is to adviseou that the Fund has a good faith belief that the hearing aid benefit, the adult dental andision benefits, and the orthodontic benefit are not essential benefits, as that term is used ihe PPACA, and therefore the Fund is not applying for an annual limits waiver relating to suenefits.

UFCW L ONE:000028


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pplicable regulations. These Plans are prepared to comply with the PPACA requirementspplicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund'snderstanding that Plans S, T and U will not be grandfathered, effective January 1, 2011.

These Plans are prepared to comply with the PPACA requirements applicable to non-randfathered plans, effective January 1, 2011.

Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Unioocal One and the Fund's various participating employers that call for contributions to theund. Th ffective and expiration dates of the current collective bargaining agreementsovering % of the Fund's participants are as follows:

4/6/2008-4/2/20114/27/2008-4/23/2011

/3/2008-7/30/2011

Should you have any questions, please contact the Fund office.


ndrea D. Goldberger


911 Airport Road

riskany, NY 13424

15-797-9600, ext 2253

ax: 315-797-9664

rom: Keels, Lisa (HHS/OCIIO) [mailto:[email protected]]

ent: Friday, December 17, 2010 2:53 PMo: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Andrea:


I. Please complete the entire annual limits spreadsheet, which is attached to this email. Please return the

completed spreadsheet to this email address as an attachment. We will only be able to process spreadshthat are fully complete (i.e., every cell should contain the information requested). If a cell on thespreadsheet does not pertain to your plan, please write None, and/or provide an explanation regardingwhy you are unable to complete that particular cell in a separate document.



UFCW L ONE:000029


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benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not beissued regarding this matter, we rely on the Interim Final Regulations, which state that, [f]or plan years . .beginning before the issuance of regulations defining essential health benefits, for purposes of enforcementhe Departments will take into account good faith efforts to comply with a reasonable interpretation of the tessential health benefits. (Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Dobelieve in good faith that hearing aids are not considered essential health benefits? If so, please confirm tyou are not applying for a waiver on the hearing aid limits.








hank you,isa

sa M. Keels, J.D.

.S. Department of Health & Human Servicesffice of Consumer Information and Insurance Oversight

ffice of Oversight

[email protected]

01-492-4168

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///co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%20response%2012.28.10.txt[11/15/2011 11:37:2

rom: Keels, Lisa (HHS/OCIIO)ent: Tuesday, December 28, 2010 7:45 PMo: Habit, Sandra (HHS/OCIIO)ubject: FW: UFCW Local One Health Care Fund Waiver Application -

Request for Additional Information

_______________________________________

rom: Keels, Lisa (HHS/OCIIO)ent: Tuesday, December 28, 2010 7:44 PMo: [email protected]: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

hanks, Andrea. Happy New Year to you, too!

isa_______________________________________rom: [email protected] [[email protected]]ent: Tuesday, December 28, 2010 7:35 PMo: Keels, Lisa (HHS/OCIIO)

ubject: Re: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Hi Lisa,

We are eliminating the lifetime limits. Thank you for checking in - I will be in my office all day tomorrow if you no speak with me.

Happy New Year!

Andrea

ent from my Verizon Wireless Phone

---- Reply message -----rom: "Keels, Lisa (HHS/OCIIO)"

Date: Tue, Dec 28, 2010 6:54 pmubject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Informationo: "[email protected]"

Cc: "Habit, Sandra (HHS/OCIIO)"

Hi again, Andrea,

hope you're doing well. I just wanted to check in about my email below. As I mentioned, as soon as you confirmhat you are either removing the lifetime limits or converting them to annual limits, we can process your applicationlease let me know if you have any questions. I am working tomorrow (Wednesday) morning.

hank you again,isa_______________________________________rom: Keels, Lisa (HHS/OCIIO)ent: Monday, December 27, 2010 7:56 AMo: [email protected]

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Cc: Habit, Sandra (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Hi Andrea,


Regarding the lifetime limits, I double checked, and the regulations state that lifetime limits need to be removed forlans beginning on or after September 23, 2010. ("the provisions of PHS Act section 2711, insofar as it relates to

fetime limits,...apply to grandfathered health plans for plan years beginning on or after September 23, 2010." See CFR 147.140(d)).. In light of the regulation, can you please confirm that you are either removing the lifetime limitonverting them to annual limits for all plans (both grandfathered and non-grandfathered)?

hank you again for your other responses and clarifications. Once you confirm that you are removing or convertinhe lifetime limits, we will move forward with the application for Plan M (the mini-wrap plan) and the Funds Retioverage.

Have a great day,isa

rom: Andrea D Goldberger [mailto:[email protected]]ent: Thursday, December 23, 2010 3:37 PMo: Keels, Lisa (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Hi Lisa sorry I missed your call! Regarding your questions, please see my comments below. Initially, we includell plans with our application because the Plans have annual limits on orthodontia, dental, vision and hearing aids.ince at this time we do not believe that these fall under the definition of essential benefits, we did not include theslans on the spreadsheet.

Our office is closed on Monday, however I will be working remotely and can be reached by email or by cell at 51857-9822.

hank you, and Enjoy the Holiday!!

Andrea



UFCW L ONE:000032


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///co-adshare/...sing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.28.10.txt[11/15/2011 11:37:

rom: Keels, Lisa (HHS/OCIIO)ent: Tuesday, December 28, 2010 6:55 PMo: [email protected]

Cc: Habit, Sandra (HHS/OCIIO)ubject: RE: UFCW Local One Health Care Fund Waiver Application -

Request for Additional Information

Hi again, Andrea,

hope you're doing well. I just wanted to check in about my email below. As I mentioned, as soon as you confirmhat you are either removing the lifetime limits or converting them to annual limits, we can process your applicationlease let me know if you have any questions. I am working tomorrow (Wednesday) morning.

hank you again,isa_______________________________________rom: Keels, Lisa (HHS/OCIIO)ent: Monday, December 27, 2010 7:56 AMo: [email protected]

Cc: Habit, Sandra (HHS/OCIIO)

ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Hi Andrea,


Regarding the lifetime limits, I double checked, and the regulations state that lifetime limits need to be removed forlans beginning on or after September 23, 2010. ("the provisions of PHS Act section 2711, insofar as it relates tofetime limits,...apply to grandfathered health plans for plan years beginning on or after September 23, 2010." See

CFR 147.140(d)). In light of the regulation, can you please confirm that you are either removing the lifetime limitsonverting them to annual limits for all plans (both grandfathered and non-grandfathered)?

hank you again for your other responses and clarifications. Once you confirm that you are removing or convertinhe lifetime limits, we will move forward with the application for Plan M (the mini-wrap plan) and the Funds Retioverage.

Have a great day,isa



Hi Lisa sorry I missed your call! Regarding your questions, please see my comments below. Initially, we includell plans with our application because the Plans have annual limits on orthodontia, dental, vision and hearing aids.ince at this time we do not believe that these fall under the definition of essential benefits, we did not include theslans on the spreadsheet.

Our office is closed on Monday, however I will be working remotely and can be reached by email or by cell at 51857-9822.

hank you, and Enjoy the Holiday!!

UFCW L ONE:000033


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Andrea



_______________________________rom: Keels, Lisa (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, December 23, 2010 3:24 PMo: [email protected]

Cc: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon MGoodman'


hank you, Andrea. I do have a couple of questions about the spreadsheet, and I just left you a voicemail messageegarding this:

. I was wondering whether you are only applying for a waiver for the Funds Retiree coverage and Plan M. Inow that those are the only two applications listed on the spreadsheet, but your original application provides SPDsther plans. Some of these plans have lifetime limits of $ Please confirm that you are either removing thfetime limits or converting them to annual limits (which do not require a waiver this year because the limit wouldbove $750,000). The lifetime limits will be eliminated for all non-grandfathered plans effective 1/1/2011. Thefetime limits for grandfathered plans will remain for Plan year 2011 as I believe that this is allowed.

. Also, for Plan M, the annual limit is listed as $ on the spreadsheet. I assume that there is no overall annmit, and that the $ is the limit on preventive care, as is stated in your original application. Please confirm

whether this is the case, and I will change the spreadsheet to reflect this. Yes, you are correct. The $ is actually nnual limit on the amount paid for an annual physical. This Plan is a supplemental plan that has no hospitalization

major medical coverage, but encourages an annual physical.

. Is Plan M the Mini-Wrap Plan included in your original application? I notice that that plan has a $ limn preventive care, so Im assuming they are the same. However, please confirm. Yes sorry! Mini-wrap and Pla

M are one and the same!

As I mentioned in my voicemail, I am out of the office now through next week. However, I will be checking mymail intermittently, and I will respond to you as quickly as possible.


isa


Cc: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon MUFCW L ONE:000034


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Goodman'ubject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Ms. Keels,

his is in response to your below request for additional information concerning the annual limits waiver application

he UFCW Local One Health Care Fund ("Fund").

The completed spreadsheet includes information pertaining to the Funds Retiree coverage and Plan M, aupplemental benefit Plan that does not include hospitalization or major medical coverage.

I. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1, 2011. The Fund ispplying to HHS for an annual limits waiver relating to retiree benefits under the Plan, so that the Fund may retain

urrent $ limit on retiree benefits, only now, on an annual basis.

n its waiver application, the Fund indicated that it intended to apply for a waiver relating to limits on the essentialenefits available under the Plan. Per your request, this is to advise you that the Fund has a good faith belief that thearing aid benefit, the adult dental and vision benefits, and the orthodontic benefit are not essential benefits, as thaerm is used in the PPACA, and therefore the Fund is not applying for an annual limits waiver relating to such bene

he Fund was in existence prior to March 23, 2010. It is the Fund's understanding that Plans Q, R and M meet theequirements of a "grandfathered plan," as that term is used in applicable regulations. These Plans are prepared toomply with the PPACA requirements applicable to grandfathered plans, effective January 1, 2011. Further, it is thund's understanding that Plans S, T and U will not be grandfathered, effective January 1, 2011. These Plans arerepared to comply with the PPACA requirements applicable to non-grandfathered plans, effective January 1, 2011

Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Union Local One and theund's various participating employers that call for contributions to the Fund. The effective and expiration dates ofurrent collective bargaining agreements covering % of the Fund's participants are as follows:

/6/2008-4/2/2011

/27/2008-4/23/2011

/3/2008-7/30/2011

hould you have any questions, please contact the Fund office.UFCW L ONE:000035


36/61


hank you and Happy Holidays,



_______________________________rom: Keels, Lisa (HHS/OCIIO) [mailto:[email protected]]ent: Friday, December 17, 2010 2:53 PMo: [email protected]

Cc: Habit, Sandra (HHS/OCIIO)ubject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information

Dear Andrea:


Please complete the entire annual limits spreadsheet, which is attached to this email. Please return theompleted spreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet does not perto your plan, please write None, and/or provide an explanation regarding why you are unable to complete thatarticular cell in a separate document.

I. In addition, please provide the following information:

As we discussed, please confirm that, pending a waiver, you plan to convert the $ lifetime limit on retirnd their spouses to an annual limit, and that you are applying for a waiver on the $ annual limit on retirees aheir spouses.

As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential healthenefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issuegarding this matter, we rely on the Interim Final Regulations, which state that, [f]or plan years . . . beginning befhe issuance of regulations defining essential health benefits, for purposes of enforcement, the Departments will tanto account good faith efforts to comply with a reasonable interpretation of the term essential health benefits.Federal Register, Vol. 75, No. 123, page 37191 (Monday, June 28, 2010)). Do you believe in good faith that heariids are not considered essential health benefits? If so, please confirm that you are not applying for a waiver on earing aid limits.

UFCW L ONE:000036


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Also as we discussed, please confirm that you are not applying for a waiver on adult orthodontic, optical, andental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you hhem.

Please confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance wrandfathering provisions, pursuant to 45 CFR 147.140?



n order to complete your application, please provide this information by 5:00pm, December 20, 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,isa

isa M. Keels, J.D.U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office ofOversight [email protected]

01-492-4168

UFCW L ONE:000037


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rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 30, 2010 4:16 PM

To: '[email protected]'ubject: UFCW Local One Health Care Fund Approval Letter for a Waiver of the Annual Limits Requirements 120-2010

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdfood Afternoon,

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

ection 2711 for UFCW Local One Health Care Fund. HHS has reviewed your application and made its

etermination. Please see the attached letter. The following plans have been approved:

Plan M

Retiree

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

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

incerely

andy Habit

epartment of Health and Human Services


01-492-4175

[email protected]

UFCW L ONE:000038
mailto:[email protected]:[email protected]


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UFCW L ONE:000040


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UFCW L ONE:000041


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rom: [email protected]: Thursday, December 30, 2010 5:45 PMo: Habit, Sandra (HHS/OCIIO)

Subject: Re: UFCW Local One Health Care Fund Approval Letter for a Waiver of the Annual LimitsRequirements 12-30-2010Dear Sandy,

We are writing to acknowledge receipt of your email approving the waiver application for Plan M and theRetiree benefit provided by the UFCW Local One Health Care Fund.

hank you for your department's assistance and quick response.

appy New Year,ndrea Goldberger

ent from my Verizon Wireless Phone

---- Reply message -----rom: "Habit, Sandra (HHS/OCIIO)"

Date: Thu, Dec 30, 2010 4:15 pmubject: UFCW Local One Health Care Fund Approval Letter for a Waiver of the Annual Limits Requireme

2-30-2010o: "'[email protected]'"

Good Afternoon,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Actection 2711 for UFCW Local One Health Care Fund.. HHS has reviewed your application and made itsetermination. Please see the attached letter. The following plans have been approved:lan M

Retiree

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

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

incerely

andy HabitDepartment of Health and Human ServicesOffice of Consumer Information and Insurance Oversight

[email protected]

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has een publicly disclosed and may be privileged and confidential. It is for internal government use only an

must not be disseminated, distributed, or copied to persons not authorized to receive the information.Unauthorized disclosures may result in prosecution to the full extent of the law.

UFCW L ONE:000042


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UFCW L ONE:000043


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rom: Keels, Lisa (HHS/OCIIO)ent: Monday, January 24, 2011 4:08 PM

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

ubject: FW: Your application for a waiver of annual limiitsi Jane,

lease see below. Andrea confirmed that she received an approval letter from Sandy on 12/30. Im not sure about the G

rive, but they were officially approved.

hanks,

sa

rom: Andrews, Jane (HHS/OCIIO)ent: Tuesday, January 04, 2011 3:51 PMo: '[email protected]'c: Keels, Lisa (HHS/OCIIO); Habit, Sandra (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

am glad you are all set. Thank you and happy new year to you.

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





rom: Andrea D Goldberger [mailto:[email protected]]ent: Tuesday, January 04, 2011 3:24 PMo: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

Dear Jane,

We received the same email from Lisa Keels and responded. When we received this initialmail from you, we thought it was a duplicate in error and did not respond I apologize foot contacting you sooner.

We did receive a letter of approval from Sandra Habit on 12/30/10. Please let me know if ywould like me to forward a copy of the email to you.

hank you and Happy New Year,Andrea

ndrea D. GoldbergerUFCW Local One Benefit Funds

911 Airport RoadOriskany, NY 13424

UFCW L ONE:000044


45/61


15-797-9600, ext 2253ax: 315-797-9664

rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, January 04, 2011 3:28 PMo: '[email protected]'c: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

lease confirm that you received this e-mail from me. Thank you.

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)



This information has not been publicly disclosed and may be privileged and confidential. It is for internal governm

use only and must not be disseminated, distributed, or copied to persons not authorized to receive the informatioUnauthorized disclosure may result in prosecution to the full extent of the law.

rom: Andrews, Jane (HHS/OCIIO)ent: Monday, December 20, 2010 11:22 AMo: '[email protected]'ubject: Your application for a waiver of annual limiits

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 the email] [and available at:

http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html]. Please return the completed spreadshto this email address as an attachment. We will only be able to process spreadsheets that are fully comp(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain tyour plan, please write None, and/or provide an explanation regarding why you are unable to completethat particular cell in a separate document.

II. In addition, if you did not include the following information in your application and is applicable, pleasprovide the following information:






If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance


n order to complete your application, please provide this information by 5:00 pm, December 22, 2010. Once thisUFCW L ONE:000045


46/61


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


ane W. Andrews

CIIO


01-492-4122 (desk)





UFCW L ONE:000046


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rom: Andrews, Jane (HHS/OCIIO)ent: Tuesday, January 04, 2011 3:51 PM

To: '[email protected]'Cc: Keels, Lisa (HHS/OCIIO); Habit, Sandra (HHS/OCIIO)

ubject: RE: Your application for a waiver of annual limiitsam glad you are all set. Thank you and happy new year to you.

ane W. Andrews

CIIO


01-492-4122 (desk)





rom: Andrea D Goldberger [mailto:[email protected]]

ent: Tuesday, January 04, 2011 3:24 PMo: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

Dear Jane,

We received the same email from Lisa Keels and responded. When we received this initialmail from you, we thought it was a duplicate in error and did not respond I apologize foot contacting you sooner.

We did receive a letter of approval from Sandra Habit on 12/30/10. Please let me know if ywould like me to forward a copy of the email to you.

hank you and Happy New Year,Andrea

ndrea D. GoldbergerUFCW Local One Benefit Funds

911 Airport RoadOriskany, NY 13424

15-797-9600, ext 2253ax: 315-797-9664

rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, January 04, 2011 3:28 PMo: '[email protected]'c: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

lease confirm that you received this e-mail from me. Thank you.

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

UFCW L ONE:000047


48/61


01-492-4122 (desk)





rom: Andrews, Jane (HHS/OCIIO)ent: Monday, December 20, 2010 11:22 AMo: '[email protected]'ubject: Your application for a waiver of annual limiits

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 the email] [and available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html]. Please return the completed spreadshto this email address as an attachment. We will only be able to process spreadsheets that are fully comp(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain t

your plan, please write None, and/or provide an explanation regarding why you are unable to completethat particular cell in a separate document.

II. In addition, if you did not include the following information in your application and is applicable, pleaseprovide the following information:






If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance,


n order to complete your application, please provide this information by 5:00 pm, December 22, 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


ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)


UFCW L ONE:000048


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///co-adshare/...Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Status%20update%201.24.11.htm[11/15/2011 11:37

rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 24, 2011 3:58 PM

To: Keels, Lisa (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)

ubject: What Happened with UFCW Local district One?think they were one we were duplicating efforts one. I have not been actively pursuing that ones completion, however, when

ok at the folder for UFCW local district one, I dont see that they have been completed or approved. Can you please give a s

pdate? Thanks!

ane W. AndrewsCIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





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rom: Andrews, Jane (HHS/OCIIO)ent: Tuesday, January 25, 2011 8:20 AM

To: Habit, Sandra (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiitshank you!

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 2081401-492-4122 (desk)





rom: Habit, Sandra (HHS/OCIIO)ent: Monday, January 24, 2011 5:13 PM

o: Andrews, Jane (HHS/OCIIO); Keels, Lisa (HHS/OCIIO)c: Pham, Erica (HHS/OCIIO); Botwinick, Alexandra (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

moved UFCW District Local One into UFCW Local One Health Care Fund.

andy

rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 24, 2011 4:57 PMo: Habit, Sandra (HHS/OCIIO); Keels, Lisa (HHS/OCIIO)c: Pham, Erica (HHS/OCIIO); Botwinick, Alexandra (HHS/OCIIO)

ubject: RE: Your application for a waiver of annual limiits

andy - Would you be able to look at the original application and make a determination about its correct name (maybe Alex or

rica know its corrected name for the public list) and then consolidate the folders so we dont have dupes? Thanks.

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





rom: Habit, Sandra (HHS/OCIIO)ent: Monday, January 24, 2011 4:41 PMo: Andrews, Jane (HHS/OCIIO); Keels, Lisa (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

he approval is in UFCW Local One Health Care Fund not UFCW District Union Local One. They appear to be duplicate files

UFCW L ONE:000051


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oth folders contain correspondence to Andrea and the applications are identical.

andy

rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 24, 2011 4:13 PMo: Keels, Lisa (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limiits

andy can you please check to see why their approval did not get on G Drive? Thanks a lot!

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)



This information has not been publicly disclosed and may be privileged and confidential. It is for internal governmuse only and must not be disseminated, distributed, or copied to persons not authorized to receive the informatioUnauthorized disclosure may result in prosecution to the full extent of the law.

rom: Keels, Lisa (HHS/OCIIO)ent: Monday, January 24, 2011 4:08 PMo: Andrews, Jane (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: FW: Your applic

ufcw local one - redacted hwm

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