From: Russell Brown [russb@benadmsys.

com] Sent: Tuesday, November 30, 2010 5:35 PM To: HHS HealthInsurance (HHS) Cc: 'Bill Pohlman'; 'Jim Ringland'; 'Marty Joseph' Subject: WAIVER
Attached is an Annual Limits waiver application with supporting documentation. I apologize for the late timing in filing the request as this is a 1/1/2011 Plan. It took us longer to analyze the impact than expected. If there is additional information needed or clarifications on information submitted, I will be glad to assist. Thank you for your review Russell Brown Director Market Services Benefit Administrative Systems, LLC (Claim Administrator for Plan) 708-647-3417

Attachments: Signed Waiver Attestation.pdf; Waiver Annual Limits.pdf

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file:////co-adshare/...aivers%20-%20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/WAIVER.htm[11/14/2011 11:02:08 AM]

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From: Andrews, Jane (HHS/OCIIO) Sent: Saturday, December 18, 2010 4:58 PM To: Andrews, Jane (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: Your application for a waiver of annual limits requirements Attachments: Waiver Application Form.xls Thank 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 spreadsheet to this email address as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None, and/or provide an explanation regarding why you are unable to complete that particular cell in a separate document. II. In addition, if you did not include the following information in your application and is applicable, please provide the following information: Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with grandfathering provisions, pursuant to 45 CFR 147.140? Confirm whether the plan was created pursuant to the Taft-Hartley Act. If is 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. In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once this information is received and the application is complete, it will be processed by the Department of Health and Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision. Thank you and feel free to contact me with questions.

Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (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 government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
GLISTER:000021

file:////co-adshare/...OI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%2012.18.10.htm[11/14/2011 11:02:09 AM]

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ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name Applicant ABC Applicant ABC

Policy Name (use a new row for each Applicant policy (Plan/ Policy application) Situs) City Plan 1 Plan 1 Washington Washington

Applicant (Plan/ Policy Plan/ Policy Situs) Effective Date Contact State (mm/dd/yyyy) Name DC DC 01/01/2011 01/01/2011 Jane Doe Jane Doe

Street Address 100 ABC Drive 100 ABC Drive

City Washington Washington

State DC DC

Phone Number (including Zip Code area code) 1-800-ABC20201 1234 1-800-ABC20202 1234

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Email Address abc@abchea lthplan.com Limited Benefit abc@abchea lthplan.com Limited Benefit Yes Yes

Total Number of Individuals Covered by Type of Current Policy Coverage Plan Overall (include all (e.g., Limited SelfAnnual Benefit, HRA, Insured Individual or dependents Limit (in Rx only, Other) (Yes/No) Group Policy covered) dollars) Group Group 4,000 2,500 $100,000 $100,000

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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PRA Disclosure Statement

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ANNUAL LIMIT WAIVER APPLICATION 2010

Ambulatory None None

Emergency None None

Hospitalization None None

Laboratory None None

Pediatric None None

Maternity/ Newborn None None

Mental Health/ Substance Abuse None None

Rehabilitative/ Devices None None

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Preventive/ Wellness None Prescription $3,000.00 $500.00

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

R Office Visit Hospital Inpatient Emergency Room Copays/Coinsurance Copay/Coinsurance Copay/Coinsurance Copay/Co

Coinsura Coinsura nce (if Copay (if nce (if Copay (if Copay (if Coinsuranc Copay (if Plan applicabl e (if applicabl applicabl applicabl applicabl applicabl e) e) e) e) Deductible e) applicable) e) $15.00 50.00% 50.00% $100.00 $100.00 50.00% 50.00% $100.00 $100.00 50.00% 50.00% $10.00 $10.00

None

$3,000.00

$1,000.00

$15.00

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ANNUAL LIMIT WAIVER APPLICATION 2010

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Rx ninsurance

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

Coinsuran Employee Employer ce (if Individual/ Employee contribution contribution applicable) Tier* (if applicable) (if applicable) None None Employee Employee + Family $100.00 $105.00 $600.00 $1,100.00

Total $700.00 $1,205.00

Employee Employer contribution contribution (if applicable) (if applicable) $110.00 $115.00 $650.00 $1,150.00

Total $760.00 $1,265.00

Employee Employer contribution contribution (if applicable) (if applicable) $125.00 $150.00 $800.00

Total

Decrease in Access to Benefits that Projected Rate Increase would result that would result from from compliance with $750,000 compliance Annual Limit Restriction with $750,000 (in dollars)(Average Annual Limit Premium by Individual) Restriction (Difference of Column AT (describe and AQ divided by briefly in cell Column AQ) or in a 21.71% None None

Plan Administr ator/ CEO of Health Insuranc e Issuer Name Jane Doe Jane Doe

Title of Individual Providing Attestation Plan Administrator Plan Administrator

$925.00

$1,400.00

$1,550.00

22.53%

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

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From: Russell Brown [mailto:russb@benadmsys.com] Sent: Monday, January 10, 2011 8:51 AM To: Andrews, Jane (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limits requirements

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 government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
From: Russell Brown [mailto:russb@benadmsys.com] Sent: Tuesday, December 21, 2010 3:35 PM To: Andrews, Jane (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limits requirements

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file:////co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:28 AM]

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I have incorporated the spreadsheet and I have the data I need for that. However, do you have answer to the questions below about whether you are a Taft Hartley plan, and if so when does the cba expire, and your compliance with the grandfather regulation. Thanks. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)

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From: Andrews, Jane (HHS/OCIIO) [mailto:Jane.Andrews@hhs.gov] Sent: Friday, January 07, 2011 4:36 PM To: 'Russell Brown' Subject: RE: Your application for a waiver of annual limits requirements

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The Plan is not Taft Hartley and it does not plan on maintaining Grandfather status

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

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Thank you. The application for Gilster-Mary Lee Corporation Group is now complete. The applicant should be hearing soon with a determination. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)

From: Andrews, Jane (HHS/OCIIO) Sent: Monday, January 10, 2011 10:49 AM To: 'Russell Brown' Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limits requirements

Attached is the waiver application and a copy of the attestation submitted in late November 2010. Thank you for your assistance Russell Brown From: Andrews, Jane (HHS/OCIIO) [mailto:Jane.Andrews@hhs.gov] Sent: Saturday, December 18, 2010 3:58 PM To: Andrews, Jane (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: Your application for a waiver of annual limits requirements

Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (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 government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
GLISTER:000026

file:////co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:28 AM]

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Thank 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 spreadsheet to this email address as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None, and/or provide an explanation regarding why you are unable to complete that particular cell in a separate document. II. In addition, if you did not include the following information in your application and is applicable, please provide the following information: Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with grandfathering provisions, pursuant to 45 CFR 147.140? Confirm whether the plan was created pursuant to the Taft-Hartley Act. If is 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. In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once this information is received and the application is complete, it will be processed by the Department of Health and Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision. Thank you and feel free to contact me with questions.

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

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file:////co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:28 AM]

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From: Andrews, Jane (HHS/OCIIO) Sent: Monday, January 10, 2011 10:59 AM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Your application for a waiver of annual limits requirements
Apologize if this is a dupe, but I dont see that I forwarded it to be file in Gilster-Mary Lee Corpor file. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)

Attachments: Waiver Application Form.xls; signed waiver attestation 2.pdf

From: Russell Brown [mailto:russb@benadmsys.com] Sent: Tuesday, January 04, 2011 3:46 PM To: Andrews, Jane (HHS/OCIIO) Subject: FW: Your application for a waiver of annual limits requirements

Thank 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 spreadsheet to this email address as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None, and/or provide an explanation regarding why you are unable to complete that particular cell in a separate document. II. In addition, if you did not include the following information in your application and is applicable, please provide the following information:
GLISTER:000028

file:////co-adshare/...cessing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%20response%201.4.11.htm[11/14/2011 11:02:29 AM]

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From: Andrews, Jane (HHS/OCIIO) [mailto:Jane.Andrews@hhs.gov] Sent: Saturday, December 18, 2010 3:58 PM To: Andrews, Jane (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: Your application for a waiver of annual limits requirements

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Attached is the waiver application and a copy of the attestation submitted in late November 2010. Thank you for your assistance Russell Brown

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From: Russell Brown [mailto:russb@benadmsys.com] Sent: Tuesday, December 21, 2010 2:35 PM To: 'Andrews, Jane (HHS/OCIIO)' Subject: RE: Your application for a waiver of annual limits requirements

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

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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 is is, please provide the date the collective bargaining agreement will expire. Confirm that your plan is either self-insured or fully insured.

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

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Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)

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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. In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once this information is received and the application is complete, it will be processed by the Department of Health and Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision. Thank you and feel free to contact me with questions.

file:////co-adshare/...cessing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%20response%201.4.11.htm[11/14/2011 11:02:29 AM]

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ANNUAL LIMIT WAIVER APPLICATION 2010

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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PRA Disclosure Statement

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Policy Name Annual Limit Waiver (use a new row for each Applicant Request policy (Plan/ Policy Applicant application) Situs) City Name Applicant Plan 1 Washington ABC Applicant ABC Plan 1 Washington Mary Lee Corp rporation Group Chester Mary Lee Corp rporation Group Chester

Applicant (Plan/ Policy Plan/ Policy Situs) Effective Date Contact State (mm/dd/yyyy) Name DC DC IL IL 01/01/2011 01/01/2011 01/01/2011 01/01/2011

Street Address City State 100 ABC Jane Doe Washington DC Drive 100 ABC Jane Doe Drive Washington DC Karen Lowry 1037 State St Chester IL Karen Lowry 1037 State St Chester IL

Phone Number (including Email Zip Code area code) Address 1-800-ABC- abc@abchea 20201 lthplan.com Limited Benefit 1234 1-800-ABC- abc@abchea 20202 1234 lthplan.com Limited Benefit 62233 618-826-2361@gilstermaryle other 62233 618-826-2361@gilstermaryle other

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Yes Yes Yes Yes

Total Number of Individuals Covered by Type of Current Policy Coverage Plan Overall (include all (e.g., Limited SelfAnnual Benefit, HRA, Insured Individual or dependents Limit (in Rx only, Other) (Yes/No) Group Policy covered) dollars) Group 4,000 2,500 $100,000 $100,000
(b)(4)

Group Group Group

GLISTER:000030

ANNUAL LIMIT WAIVER APPLICATION 2010

Ambulatory None

Emergency None

Hospitalization None

Laboratory None

Pediatric None

Maternity/ Newborn None

Mental Health/ Substance Abuse None

Rehabilitative/ Devices None

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Preventive/ Wellness None Prescription $3,000.00 $500.00

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

Office Visit Hospital Inpatient Emergency Room R Copays/Coinsurance Copay/Coinsurance Copay/Coinsurance Copay/Co

Coinsura Coinsura nce (if Copay (if nce (if Copay (if Copay (if Coinsuranc Copay (if Plan applicabl e (if applicabl applicabl applicabl applicabl applicabl e) e) e) e) Deductible e) applicable) e) $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00

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(b)(4)

GLISTER:000031

ANNUAL LIMIT WAIVER APPLICATION 2010

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Rx ninsurance

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

Coinsuran Employee Employer ce (if Individual/ Employee contribution contribution applicable) Tier* (if applicable) (if applicable) None Employee $100.00 $600.00

Total $700.00

Employee Employer contribution contribution (if applicable) (if applicable) $110.00 $650.00

Total $760.00

Employee Employer contribution contribution (if applicable) (if applicable) $125.00 $800.00

Total

Decrease in Access to Benefits that Projected Rate Increase would result that would result from from compliance with $750,000 compliance Annual Limit Restriction with $750,000 (in dollars)(Average Annual Limit Premium by Individual) Restriction (Difference of Column AT (describe and AQ divided by briefly in cell Column AQ) or in a 21.71% None None None None

Plan Administr ator/ CEO of Health Insuranc e Issuer Name Jane Doe

Title of Individual Providing Attestation Plan Administrator

$925.00

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

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(b)(4)

Jane Doe Plan Administrator ichael Wedg Plan Administrator ichael Wedg Plan Administrator

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(b)(4)

(b)(4)

(b)(4)

(b)(4)

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From: Botwinick, Alexandra (HHS/OCIIO) Sent: Monday, January 31, 2011 9:26 AM To: 'klowry@gilstermarylee.com' Cc: Habit, Sandra (HHS/OCIIO) Subject: Gilster-Mary Lee Corporation Waiver of the Annual Limits Requirements 1-31-2011 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Gilster-Mary Lee Corporation, Group Health Plan. HHS has reviewed your application and made its determination. Please see the attached letter. Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance.

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Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

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