UFCW Local One - Redacted HWM

From: Andrea D Goldberger [andrea_goldberger@ufcwny.
com] Sent: Tuesday, November 30, 2010 5:04 PM To: OCIIO Oversight; HHS HealthInsurance (HHS) Cc: 'Sarah E. Sanchez'; 'Barry S. Slevin'; 'Sharon M. Goodman'; 'Gingell, John' Subject: Waiver Attachments: Waiver Application.pdf Good Afternoon, Attached please find an Application for Waiver of PPACA Lifetime Limits Prohibition filed on behalf of the UFCW Local One Health Care Fund. Thank you, Andrea D. Goldberger UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424 315-797-9600, ext 2253 Fax: 315-797-9664
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UFCW L ONE:000001
file:////co-adshare/...-%20Torres/DFOI%20Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Waiver.txt[11/15/2011 11:37:20 AM]
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From: Andrea D Goldberger [andrea_goldberger@ufcwny.com] Sent: Wednesday, December 01, 2010 12:58 PM To: OCIIO Oversight; HHS HealthInsurance (HHS) Cc: 'Sarah E. Sanchez'; 'Barry S. Slevin'; 'Sharon M. Goodman'; 'Gingell, John' Subject: Waiver and SPD Attachments: Waiver Application.pdf; hc spd - 2009 8x11_FINAL.pdf; WRAPPLAN 2009.pdf; PLAN Q PPO 2009.pdf; PLAN R PPO-2009.pdf; PLAN S PPO - 1-12010.pdf; PLAN T PPO.pdf; PLAN U PPO 8-1-2010.pdf Good Afternoon, Attached please find an Application for Waiver of PPACA Lifetime Limits Prohibition filed on behalf of the UFCW Local One Health Care Fund, as well as a copy of the Fund's SPD and Plan Summaries. The Application was emailed yesterday, November 30th; however, the SPD and Summaries were inadvertently left off the email. Thank you, Andrea D. Goldberger UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424 315-797-9600, ext 2253 Fax: 315-797-9664
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file:////co-adshare/...I%20Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Waiver%20and%20SPD.txt[11/15/2011 11:37:20 AM]
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Ex. 4
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Ex. Ex. Ex. Ex. Ex. Ex. Ex. 4 4 4 4 4 4 4 Ex. 4 Ex. 4 Ex. 4
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UFCW L ONE:000004
Ex. 4
UFCW L ONE:000005
Mr. James Mayhew Page 4 (andeventhen may decidenot to increase agreement expiresand is renegotiated costs the increased contributions.) Thus, the Fund's only option for addressing involved in eliminating the lifetime limits described above likely is to offeredby the Fund. or otherbenefits reduce these benefits significantly
6.
of the informationabove,signedby the Chairmanand The requiredattestation as AttachmentA to is enclosed of the Fund's Board of Trustees, Co-Chairman this letter.
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We respectfullyrequestexpeditedhandling of this matter. If you have any please theundersigned. contact questions information, or needadditional Sincerely, l \ . -
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:TKE:kdM233.01 SMG:SES Enclosures cc:
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(w/o encl.) Boardof Trustees Esq.(w/o encl.) M. Goodman, Sharon JohnGingell(w/o encl.)
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D Arurv\</,L ftft/^ro /Rndrea D. Goldberger

Director FundAdministrative
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will not grantthe Funda waiver of HealthandHumanServices If the Department herein,but would granta waiverfor suchlimits if of the lifetime limits described will amendthe to annuallimits, the Board of Trustees they are first converted limits, effectiveJanuary1, lifetime limits to annual Planto convertthe referenced a waiverof suchannuallimits. 2011,andherebyseeks
UFCW L ONE:000006
ArrncnmENT A UFCW Locu, Oun Hn.lr,rn Canr FuNo %rVNN APPLICATION PPACA LrnnrlnnnLTNNNS AtvrrNIstn lroR Attnsr,luoN oF Pr,.q,N
of the UFCW Local One Health Care Fund (ooFund"), On behalf of the Board of Trustees the undersigned,Chairman and Co-Chairmanof the UFCW Local One Health Care Fund, do hereby attestto the following:
(1) theFundwasin forceprior to September 23,2010;and
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(2) basedupon the information containedin the Fund's letter to which this Attestation is attachedas Exhibit A ("Letter"), the elimination of the lifetime limits referenced in the Letter, and the application of restricted annual limits to the benefits referenced in the Letter, would result in a significant decreasein accessto benefits for those currently coveredby the Plan and/or a significant increasein the amountsneededto cover the cost of the Plan.
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One Health Care Plan
I One Health Care Plan
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Pages 8 through 155 redacted for the following reasons: ------------------------------------------------Exemption 4
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From: Keels, Lisa (HHS/OCIIO) Sent: Friday, December 17, 2010 2:53 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information Attachments: Waiver Application Form.xlsx Dear Andrea: Thank you for speaking with me today and 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, 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 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, please provide the following information: As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4 lifetime limit on retirees and their spouses to an annual limit, and that you are applying for a waiver on the $Ex. 4 annual limit on retirees and their spouses. As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered essential health benefits? If so, please confirm that you 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, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them. Please 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? 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. In order to complete your application, please provide this information by 5:00pm, December 20, 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, Lisa
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file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.17.10.htm[11/15/2011 11:37:22 AM]
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UFCW L ONE:000009
Lisa M. Keels, J.D. U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office of Oversight lisa.keels@hhs.gov 301-492-4168
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From: Andrews, Jane (HHS/OCIIO) Sent: Monday, December 20, 2010 10:20 AM To: Andrews, Jane (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: Your application for a waiver of annual limiits 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 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. In order to complete your application, please provide this information by 5:00 pm, December 22, 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.
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Ms. Keels-
Sarah Sanchez
Sarah E. Sanchez Principal Slevin & Hart, P.C. 1625 Massachusetts Ave., N.W., Suite 450 Washington, D.C. 20036 202-797-8700 Tel 202-234-8231 Fax ssanchez@slevinhart.com
IRS CIRCULAR 230 NOTICE: To comply with requirements imposed by the IRS, this is to inform you that any tax advice contained in this communication (including any attachments) was not intended or written to be used, and cannot be used, for the purpose of (i) avoiding tax-related penalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any matter addressed herein.
The information contained in this message is intended only for the use of the designated recipients named above. This message may be an attorney-client communication, and as such, is privileged and confidential If the reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error, and that any review, dissemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please notify us
UFCW L ONE:000012
file:////co-adshare/...ocal%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20correspondence%2012.20.10.htm[11/15/2011 11:37:23 AM]
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This firm represents the UFCW Local One Health Care Fund. This is in response to your below email to the Fund Director, Andrea Goldberger. The Fund is in the process ofputting togetherthedata necessary to respond to your request for additional information. However, it is unlikely that the Fund will be able to respond by 5pm today. The Fund will make every attempt to provide you with the requested information by Thursday of this week. Please let me know if that presents any problem. Thanks.
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From: Sarah E. Sanchez [mailto:ssanchez@slevinhart.com] Sent: Monday, December 20, 2010 10:44 AM To: Keels, Lisa (HHS/OCIIO) Cc: andrea_goldberger@ufcwny.com; Price, Francoise; Gingell, John; Sharon M. Goodman Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
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From: Keels, Lisa (HHS/OCIIO) Sent: Monday, December 20, 2010 10:59 AM To: Sarah E. Sanchez Cc: andrea_goldberger@ufcwny.com; Price, Francoise; Gingell, John; Sharon M. Goodman; Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information Dear Ms. Sanchez, Thank you for your email and for letting me know about the Funds schedule. HHS will process your application as quickly 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. Please feel free to contact me with any questions. Thank you again, Lisa Lisa M. Keels, J.D. U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office of Oversight lisa.keels@hhs.gov 301-492-4168
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immediately by telephone at (202) 797-8700. Thank you.

From: andrea_goldberger@ufcwny.com [mailto:andrea_goldberger@ufcwny.com] Sent: Monday, December 20, 2010 9:55 AM To: Gingell, John; Price, Francoise; Sarah E. Sanchez Subject: Fwd: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Good morning, I am forwarding the email received from HHS regarding the Fund's waiver application. I am in the process of completing the response and need some assistance.
Additionally, when asking for current rates, I believe the 1/1/2011 rates are what OS being requested - correct?
The response is due by 5pm EST today.
Thank you - I am available by email and cell 518-857-9823. Andrea Sent from my Verizon Wireless Phone
Dear Andrea:
Thank you for speaking with me today and 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, 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 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, please provide the following information:
UFCW L ONE:000013
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----- Forwarded message ----From: "Keels, Lisa (HHS/OCIIO)" <Lisa.Keels@hhs.gov> Date: Fri, Dec 17, 2010 2:52 pm Subject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information To: "andrea_goldberger@ufcwny.com" <andrea_goldberger@ufcwny.com> Cc: "Habit, Sandra (HHS/OCIIO)" <Sandra.Habit@hhs.gov>
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Also, under plan policy effective date, would that be the plan year date of 1/1/2011 or the date that the plan of benefits for each plan was effective? I.e. T has an effective date of 4/1/2010 and U has an eff date of 8/1/2010 and S eff date of 1/1/2011.
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The application requests information about rate increases, which I will need from Segal. The form requests the information reported for each Plan and the information previously provided was a Total Fund amount.
* As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4 lifetime limit on retirees and their spouses to an annual limit, and that you are applying for a waiver on the $ Ex. 4 annual limit on retirees and their spouses.
* Please provide the date for which the Collective Bargaining Agreement will expire. In order to complete your application, please provide this information by 5:00pm, December 20, 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, Lisa
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* Please confirm that the Collective Bargaining Agreement was ratified prior to October 3, 2008.
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* Please 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?
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* Also as we discussed, please confirm that you are not applying for a waiver on adult orthodontic, optical, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them.
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* As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered "essential health benefits?" If so, please confirm that you are not applying for a waiver on the hearing aid limits.
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ANNUAL LIMIT WAIVER APPLICATION 2010
Annual Limit Waiver Request Applicant Name
Policy Name (use a new row for each Applicant policy (Plan/ Policy application) Situs) City
Applicant (Plan/ Policy Plan/ Policy Situs) Effective Date Contact State (mm/dd/yyyy) Name
Street Address
City
State
Phone Number (including Zip Code area code)
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Email Address
Total Number of Individuals Type of Covered by Current Coverage Policy Plan Overall (e.g., Limited Self(include all Annual Benefit, HRA, Insured Individual or dependents Limit (in Rx only, Other) (Yes/No) Group Policy covered) dollars)
Ambulatory
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Oriskany NY 13424
UFCW Local One Health Care Fund
Plan M
Oriskany
NY
01/01/2011
Andrea Goldberger
5911 Airport Rd
1-315-7979600, ext 2253
andrea_gold berger@ufcw ny.com Limited Benefit
Yes
Group
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Oriskany NY 13424
Retiree
Oriskany
NY
01/01/2011
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UFCW Local One Health Care Fund
Andrea Goldberger
5911 Airport Rd
1-315-7979600, ext 2253
andrea_gold berger@ufcw ny.com Limited Benefit
Yes
Group
PRA Disclosure Statement
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Emergency
Hospitalization
Laboratory
Pediatric
Maternity/ Newborn
Mental Health/ Substance Abuse
Rehabilitative/ Devices
Preventive/ Wellness
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Current Essential Benefits Annual Limits (Annual Limit for Each Essential Benefit)
Office Visit Copays/Coinsurance
Hospital Inpatient Copay/Coinsurance
Emergency Room Copay/Coinsurance
R Copay/Co
Prescription
Coinsura Coinsura Copay (if Coinsuranc Copay (if nce (if Copay (if nce (if Copay (if Plan applicabl e (if applicabl applicabl applicabl applicabl applicabl Deductible e) applicable) e) e) e) e) e)
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Rx ninsurance
Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Current Monthly Premium Rates or Premium Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Equivalent Rates (in dollars)*: Individual)* (in dollars)*
Coinsuran Employee Employer ce (if Individual/ Employee contribution contribution applicable) Tier* (if applicable) (if applicable)
Total $0.00 $0.00
Employee Employer contribution contribution (if applicable) (if applicable)
Total $0.00 $0.00
Employee Employer contribution contribution (if applicable) (if applicable)
Total $0.00 $0.00
Decrease in Access to Benefits that would result Projected Rate Increase from that would result from compliance with $750,000 compliance Annual Limit Restriction with $750,000 Annual Limit (in dollars)(Average Restriction Premium by Individual) (describe (Difference of Column AT and AQ divided by Column briefly in cell or in a AQ) #DIV/0! #DIV/0!
Plan Administr ator/ CEO of Health Insurance Issuer Name
Title of Individual Providing Attestation
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Ex. 4
Employee
Andrea Goldberge r
Fund Director
Individual
Andrea Goldberge r
Fund Director
* 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: Keels, Lisa (HHS/OCIIO) Sent: Thursday, December 23, 2010 3:24 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon M. Goodman' Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Thank you, Andrea. I do have a couple of questions about the spreadsheet, and I just left you a voicemail message regarding this: 1. I was wondering whether you are only applying for a waiver for the Funds Retiree coverage and Plan M. I know that those are the only two applications listed on the spreadsheet, but your original application provides SPDs for other plans. Some of these plans have lifetime limits of $Ex. 4 . Please confirm that you are either removing these lifetime limits or converting them to annual limits (which do not require a waiver this year because the limit would be above $750,000). 2. Also, for Plan M, the annual limit is listed as $Ex. 4 on the spreadsheet. I assume that there is no overall annual limit, and that the $Ex. 4 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. 3. Is Plan M the Mini-Wrap Plan included in your original application? I notice that that plan has a $ Ex. 4 limit on preventive care, so Im assuming they are the same. However, please confirm. As I mentioned in my voicemail, I am out of the office now through next week. However, I will be checking my email intermittently, and I will respond to you as quickly as possible. Thank you again, and happy holidays. Lisa
From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: 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 M. Goodman' Subject: 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 annual limits waiver application of the UFCW Local One Health Care Fund ("Fund"). I. The completed spreadsheet includes information pertaining to the Funds Retiree coverage and Plan M, a supplemental benefit Plan that does not include hospitalization or major medical coverage. II. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1, 2011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefits under the Plan, so that the Fund may retain the current $Ex. 4 limit on retiree benefits, only now, on an annual basis. In its waiver application, the Fund indicated that it intended to apply for a waiver relating to limits on the essential benefits available under the Plan. Per your request, this is to advise you that the Fund has a good faith belief that the hearing aid benefit, the adult dental and
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Dear Andrea: Thank you for speaking with me today and 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, 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 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, please provide the following information:
As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4
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From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Friday, December 17, 2010 2:53 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
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Andrea D. Goldberger UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424 315-797-9600, ext 2253 Fax: 315-797-9664
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vision benefits, and the orthodontic benefit are not essential benefits, as that term is used in the PPACA, and therefore the Fund is not applying for an annual limits waiver relating to such benefits. The Fund was in existence prior to March 23, 2010. It is the Fund's understanding that Plans Q, R and M meet the requirements of a "grandfathered plan," as that term is used in applicable regulations. These Plans are prepared to comply with the PPACA requirements applicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund's understanding 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 nongrandfathered plans, effective January 1, 2011. Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Union Local One and the Fund's various participating employers that call for contributions to the Fund. The effective and expiration dates of the current collective bargaining agreements covering Ex. 4 % of the Fund's participants are as follows: 4/6/2008-4/2/2011 4/27/2008-4/23/2011 8/3/2008-7/30/2011 Should you have any questions, please contact the Fund office. Thank you and Happy Holidays,
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lifetime limit on
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retirees and their spouses to an annual limit, and that you are applying for a waiver on the $Ex. 4 annual limit on retirees and their spouses. As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered essential health benefits? If so, please confirm that you 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, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them. Please 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? 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. In order to complete your application, please provide this information by 5:00pm, December 20, 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, Lisa
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UFCW L ONE:000021
From: Keels, Lisa (HHS/OCIIO) Sent: Thursday, December 23, 2010 12:58 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Hi Andrea, Thanks for your email. To answer your question, we are requesting the effective dates of each agreement, as well as the dates each CBA expires. However, since you have 67 CBAs, at the moment, you can just provide the date the first CBA expires. We might ask for more information, but that is fine for now. Please let me know if this makes sense. Happy Holidays to you, too! Lisa
From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: Thursday, December 23, 2010 12:04 PM To: Keels, Lisa (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Dear Andrea: Thank you for speaking with me today and 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:
UFCW L ONE:000022
file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%2012.23.10.htm[11/15/2011 11:37:25 AM]
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Dear Lisa, I am forwarding our response to your request for information today and have a question regarding the information you need pertaining to collective bargaining agreements. The union has 67 collective bargaining agreements that contain provisions for health care benefits through the UFCW Local One Health Care Fund. Are you requesting the effective dates of each agreement or the earliest and more recent or something altogether different? Thank you and Happy Holidays!! Andrea Goldberger
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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 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. As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4 lifetime limit on retirees and their spouses to an annual limit, and that you are applying for a waiver on the $Ex. 4 annual limit on retirees and their spouses. As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered essential health benefits? If so, please confirm that you 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, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them. Please 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? 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. In order to complete your application, please provide this information by 5:00pm, December 20, 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, Lisa
II. In addition, please provide the following information:
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file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%2012.23.10.htm[11/15/2011 11:37:25 AM]
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UFCW L ONE:000023
From: Andrea D Goldberger [andrea_goldberger@ufcwny.com] Sent: 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 M. Goodman' Subject: 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 limits waiver application of the UFCW Local One Health Care Fund ("Fund"). I. The completed spreadsheet includes information pertaining to the Funds Retiree coverage and Plan M, a supplemental benefit Plan that does not include hospitalization or major medical coverage. II. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1, 2011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefits under the Plan, so that the Fund may retain the current $Ex. 4 limit on retiree benefits, only now, on an annual basis. In its waiver application, the Fund indicated that it intended to apply for a waiver relating to limits on the essential benefits available under the Plan. Per your request, this is to advise you that the Fund has a good faith belief that the hearing aid benefit, the adult dental and vision benefits, and the orthodontic benefit are not essential benefits, as that term is used in the PPACA, and therefore the Fund is not applying for an annual limits waiver relating to such benefits. The Fund was in existence prior to March 23, 2010. It is the Fund's understanding that Plans Q, R and M meet the requirements of a "grandfathered plan," as that term is used in applicable regulations. These Plans are prepared to comply with the PPACA requirements applicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund's understanding 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 nongrandfathered plans, effective January 1, 2011. Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Union Local One and the Fund's various participating employers that call for contributions to the Fund. The effective and expiration dates of the current collective bargaining agreements covering Ex. 4 % of the Fund's participants are as follows: 4/6/2008-4/2/2011 4/27/2008-4/23/2011 8/3/2008-7/30/2011 Should you have any questions, please contact the Fund office. Thank you and Happy Holidays,
Andrea D. Goldberger UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424
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file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%2012.23.10.htm[11/15/2011 11:37:26 AM]
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UFCW L ONE:000024
315-797-9600, ext 2253 Fax: 315-797-9664
As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4 lifetime limit on retirees and their spouses to an annual limit, and that you are applying for a waiver on the $Ex. 4 annual limit on retirees and their spouses. As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered essential health benefits? If so, please confirm that you 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, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them. Please 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? 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. In order to complete your application, please provide this information by 5:00pm, December 20, 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.
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UFCW L ONE:000025
Thank you, Lisa

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From: Keels, Lisa (HHS/OCIIO) Sent: Monday, December 27, 2010 7:57 AM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Hi Andrea, I hope you are still enjoying the holiday season! Thanks so much for your clarifications below. Regarding the lifetime limits, I double checked, and the regulations state that lifetime limits need to be removed for all plans beginning on or after September 23, 2010. ( "the provisions of PHS Act section 2711, insofar as it relates to lifetime limits,...apply
to grandfathered health plans for plan years beginning on or after September 23, 2010." See 45 CFR 147.140(d)). In light of the regulation, can you please confirm that you are either removing the lifetime limits or converting them to annual limits for all plans (both grandfathered and non-grandfathered)? Thank you again for your other responses and clarifications. Once you confirm that you are removing or converting the lifetime limits, we will move forward with the application for Plan M (the mini-wrap plan) and the Funds Retiree coverage. , Have a great day, Lisa
From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: Thursday, December 23, 2010 3:37 PM To: Keels, Lisa (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Thursday, December 23, 2010 3:24 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon M. Goodman' Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Thank you, Andrea. I do have a couple of questions about the spreadsheet, and I just left you a voicemail message regarding
UFCW L ONE:000027
file:////co-adshare/...0Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20clarification%2012.27.10.htm[11/15/2011 11:37:26 AM]
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Hi Lisa sorry I missed your call! Regarding your questions, please see my comments below. Initially, we included all plans with our application because the Plans have annual limits on orthodontia, dental, vision and hearing aids. Since at this time we do not believe that these fall under the definition of essential benefits, we did not include these Plans 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 518-857-9822. Thank you, and Enjoy the Holiday!! Andrea
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Dear Ms. Keels, This is in response to your below request for additional information concerning the annual limits waiver application of the UFCW Local One Health Care Fund ("Fund"). I. The completed spreadsheet includes information pertaining to the Funds Retiree coverage and Plan M, a supplemental benefit Plan that does not include hospitalization or major medical coverage. II. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1, 2011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefits under the Plan, so that the Fund may retain the current $Ex. 4 limit on retiree benefits, only now, on an annual basis. In its waiver application, the Fund indicated that it intended to apply for a waiver relating to limits on the essential benefits available under the Plan. Per your request, this is to advise you that the Fund has a good faith belief that the hearing aid benefit, the adult dental and vision benefits, and the orthodontic benefit are not essential benefits, as that term is used in the PPACA, and therefore the Fund is not applying for an annual limits waiver relating to such benefits.
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From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: 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 M. Goodman' Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
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this: 1. I was wondering whether you are only applying for a waiver for the Funds Retiree coverage and Plan M. I know that those are the only two applications listed on the spreadsheet, but your original application provides SPDs for other plans. Some of these plans have lifetime limits of $Ex. 4 Please confirm that you are either removing these lifetime limits or converting them to annual limits (which do not require a waiver this year because the limit would be 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 $Ex. 4 on the spreadsheet. I assume that there is no overall annual limit, and that the $Ex. 4 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 $Ex. is actually an annual 4 limit on the amount paid for an annual physical. This Plan is a supplemental plan that has no hospitalization or major 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 $Ex. 4 limit on preventive care, so Im assuming they are the same. However, please confirm. Yes sorry! Mini-wrap and Plan 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 my email intermittently, and I will respond to you as quickly as possible. Thank you again, and happy holidays. Lisa
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UFCW L ONE:000028
As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4 lifetime limit on retirees and their spouses to an annual limit, and that you are applying for a waiver on the $Ex. 4 annual limit on retirees and their spouses.
UFCW L ONE:000029
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The Fund was in existence prior to March 23, 2010. It is the Fund's understanding that Plans Q, R and M meet the requirements of a "grandfathered plan," as that term is used in applicable regulations. These Plans are prepared to comply with the PPACA requirements applicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund's understanding 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 nongrandfathered plans, effective January 1, 2011. Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Union Local One and the Fund's various participating employers that call for contributions to the Fund. Th ffective and expiration dates of the current collective bargaining agreements covering Ex. 4 % of the Fund's participants are as follows: 4/6/2008-4/2/2011 4/27/2008-4/23/2011 8/3/2008-7/30/2011 Should you have any questions, please contact the Fund office. Thank you and Happy Holidays,
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As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered essential health benefits? If so, please confirm that you 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, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them. Please 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? 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. In order to complete your application, please provide this information by 5:00pm, December 20, 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, Lisa
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UFCW L ONE:000030
From: Keels, Lisa (HHS/OCIIO) Sent: Tuesday, December 28, 2010 7:45 PM To: Habit, Sandra (HHS/OCIIO) Subject: FW: UFCW Local One Health Care Fund Waiver Application Request for Additional Information ________________________________________ From: Keels, Lisa (HHS/OCIIO) Sent: Tuesday, December 28, 2010 7:44 PM To: andrea_goldberger@ufcwny.com Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information Thanks, Andrea. Happy New Year to you, too!
Hi Lisa,
Happy New Year! Andrea
Sent from my Verizon Wireless Phone
Hi again, Andrea,
I hope you're doing well. I just wanted to check in about my email below. As I mentioned, as soon as you confirm that you are either removing the lifetime limits or converting them to annual limits, we can process your application. Please let me know if you have any questions. I am working tomorrow (Wednesday) morning. Thank you again, Lisa ________________________________________ From: Keels, Lisa (HHS/OCIIO) Sent: Monday, December 27, 2010 7:56 AM To: andrea_goldberger@ufcwny.com
UFCW L ONE:000031
file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%20response%2012.28.10.txt[11/15/2011 11:37:27 AM]
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----- Reply message ----From: "Keels, Lisa (HHS/OCIIO)" <Lisa.Keels@hhs.gov> Date: Tue, Dec 28, 2010 6:54 pm Subject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information To: "andrea_goldberger@ufcwny.com" <andrea_goldberger@ufcwny.com> Cc: "Habit, Sandra (HHS/OCIIO)" <Sandra.Habit@hhs.gov>
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We are eliminating the lifetime limits. Thank you for checking in - I will be in my office all day tomorrow if you need to speak with me.
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Lisa ________________________________________ From: andrea_goldberger@ufcwny.com [andrea_goldberger@ufcwny.com] Sent: Tuesday, December 28, 2010 7:35 PM To: Keels, Lisa (HHS/OCIIO) Subject: Re: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
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Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information Hi Andrea, I hope you are still enjoying the holiday season! Thanks so much for your clarifications below. Regarding the lifetime limits, I double checked, and the regulations state that lifetime limits need to be removed for all plans beginning on or after September 23, 2010. ("the provisions of PHS Act section 2711, insofar as it relates to lifetime limits,...apply to grandfathered health plans for plan years beginning on or after September 23, 2010." See 45 CFR 147.140(d)).. In light of the regulation, can you please confirm that you are either removing the lifetime limits or converting them to annual limits for all plans (both grandfathered and non-grandfathered)? Thank you again for your other responses and clarifications. Once you confirm that you are removing or converting the lifetime limits, we will move forward with the application for Plan M (the mini-wrap plan) and the Funds Retiree coverage. , Have a great day, Lisa From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: Thursday, December 23, 2010 3:37 PM To: Keels, Lisa (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
Our office is closed on Monday, however I will be working remotely and can be reached by email or by cell at 518857-9822. Thank you, and Enjoy the Holiday!! Andrea
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Hi Lisa sorry I missed your call! Regarding your questions, please see my comments below. Initially, we included all plans with our application because the Plans have annual limits on orthodontia, dental, vision and hearing aids. Since at this time we do not believe that these fall under the definition of essential benefits, we did not include these Plans on the spreadsheet.
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file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%20response%2012.28.10.txt[11/15/2011 11:37:27 AM]
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UFCW L ONE:000032
From: Keels, Lisa (HHS/OCIIO) Sent: Tuesday, December 28, 2010 6:55 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application Request for Additional Information Hi again, Andrea, I hope you're doing well. I just wanted to check in about my email below. As I mentioned, as soon as you confirm that you are either removing the lifetime limits or converting them to annual limits, we can process your application. Please let me know if you have any questions. I am working tomorrow (Wednesday) morning. Thank you again, Lisa ________________________________________ From: Keels, Lisa (HHS/OCIIO) Sent: Monday, December 27, 2010 7:56 AM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information Hi Andrea,
From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: Thursday, December 23, 2010 3:37 PM To: Keels, Lisa (HHS/OCIIO) Subject: 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 included all plans with our application because the Plans have annual limits on orthodontia, dental, vision and hearing aids. Since at this time we do not believe that these fall under the definition of essential benefits, we did not include these Plans 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 518857-9822. Thank you, and Enjoy the Holiday!!
UFCW L ONE:000033
file:////co-adshare/...sing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.28.10.txt[11/15/2011 11:37:28 AM]
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Thank you again for your other responses and clarifications. Once you confirm that you are removing or converting the lifetime limits, we will move forward with the application for Plan M (the mini-wrap plan) and the Funds Retiree coverage. , Have a great day, Lisa
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Regarding the lifetime limits, I double checked, and the regulations state that lifetime limits need to be removed for all plans beginning on or after September 23, 2010. ("the provisions of PHS Act section 2711, insofar as it relates to lifetime limits,...apply to grandfathered health plans for plan years beginning on or after September 23, 2010." See 45 CFR 147.140(d)). In light of the regulation, can you please confirm that you are either removing the lifetime limits or converting them to annual limits for all plans (both grandfathered and non-grandfathered)?
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I hope you are still enjoying the holiday season! Thanks so much for your clarifications below.
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Andrea Andrea D. Goldberger UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424 315-797-9600, ext 2253 Fax: 315-797-9664 ________________________________ From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Thursday, December 23, 2010 3:24 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO); 'Sarah E. Sanchez'; 'Sullivan, Susan'; 'Price, Francoise'; 'Gingell, John'; 'Sharon M. Goodman' Subject: RE: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information
2. Also, for Plan M, the annual limit is listed as $Ex. 4 on the spreadsheet. I assume that there is no overall annual limit, and that the $Ex. 4 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 $Ex. 4 is actually an annual limit on the amount paid for an annual physical. This Plan is a supplemental plan that has no hospitalization or major 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 $Ex. 4 limit on preventive care, so Im assuming they are the same. However, please confirm. Yes sorry! Mini-wrap and Plan 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 my email intermittently, and I will respond to you as quickly as possible. Thank you again, and happy holidays. Lisa From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: 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 M.
UFCW L ONE:000034
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1. I was wondering whether you are only applying for a waiver for the Funds Retiree coverage and Plan M. I know that those are the only two applications listed on the spreadsheet, but your original application provides SPDs for other plans. Some of these plans have lifetime limits of $Ex. 4 Please confirm that you are either removing these lifetime limits or converting them to annual limits (which do not require a waiver this year because the limit would be 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.
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Thank you, Andrea. I do have a couple of questions about the spreadsheet, and I just left you a voicemail message regarding this:
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Goodman' Subject: 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 annual limits waiver application of the UFCW Local One Health Care Fund ("Fund").
Currently, there are 67 collective bargaining agreements between the U.F.C.W. District Union Local One and the Fund's various participating employers that call for contributions to the Fund. The effective and expiration dates of the current collective bargaining agreements covering Ex. 4% of the Fund's participants are as follows:
4/6/2008-4/2/2011 4/27/2008-4/23/2011 8/3/2008-7/30/2011
Should you have any questions, please contact the Fund office.
UFCW L ONE:000035
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The Fund was in existence prior to March 23, 2010. It is the Fund's understanding that Plans Q, R and M meet the requirements of a "grandfathered plan," as that term is used in applicable regulations. These Plans are prepared to comply with the PPACA requirements applicable to grandfathered plans, effective January 1, 2011. Further, it is the Fund's understanding 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-grandfathered plans, effective January 1, 2011.
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In its waiver application, the Fund indicated that it intended to apply for a waiver relating to limits on the essential benefits available under the Plan. Per your request, this is to advise you that the Fund has a good faith belief that the hearing aid benefit, the adult dental and vision benefits, and the orthodontic benefit are not essential benefits, as that term is used in the PPACA, and therefore the Fund is not applying for an annual limits waiver relating to such benefits.
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II. The Fund will eliminate its current lifetime limit on retiree benefits, effective January 1, 2011. The Fund is applying to HHS for an annual limits waiver relating to retiree benefits under the Plan, so that the Fund may retain the current $Ex. 4 limit on retiree benefits, only now, on an annual basis.
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I. The completed spreadsheet includes information pertaining to the Funds Retiree coverage and Plan M, a supplemental benefit Plan that does not include hospitalization or major medical coverage.
Thank you and Happy Holidays, Andrea D. Goldberger UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424 315-797-9600, ext 2253 Fax: 315-797-9664 ________________________________ From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Friday, December 17, 2010 2:53 PM To: andrea_goldberger@ufcwny.com Cc: Habit, Sandra (HHS/OCIIO) Subject: UFCW Local One Health Care Fund Waiver Application - Request for Additional Information Dear Andrea:
Thank you for speaking with me today and 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, 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 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, please provide the following information:
As we discussed, you have benefit limits on hearing aids. Hearing aids may be considered an essential health benefit under Section 1302(b)(1)(G) of the Affordable Care Act. However, because regulations have not been issued 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 enforcement, the Departments will take into 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 hearing aids are not considered essential health benefits? If so, please confirm that you are not applying for a waiver on the hearing aid limits.
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As we discussed, please confirm that, pending a waiver, you plan to convert the $Ex. 4 lifetime limit on retirees and their spouses to an annual limit, and that you are applying for a waiver on the $Ex. 4 annual limit on retirees and their spouses.
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UFCW L ONE:000036
Also as we discussed, please confirm that you are not applying for a waiver on adult orthodontic, optical, and dental benefits, and that you are only applying for a waiver on pediatric oral and vision benefits, to the extent you have them.
Please 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?
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.
Thank you, Lisa
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In order to complete your application, please provide this information by 5:00pm, December 20, 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.
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UFCW L ONE:000037
From: Habit, Sandra (HHS/OCIIO) Sent: Thursday, December 30, 2010 4:16 PM To: 'andrea_goldberger@ufcwny.com' Subject: UFCW Local One Health Care Fund Approval Letter for a Waiver of the Annual Limits Requirements 1230-2010 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Afternoon, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for UFCW Local One Health Care Fund. HHS has reviewed your application and made its determination. Please see the attached letter. The following plans have been approved:
Plan M
Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance. Sincerely
Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@hhs.gov

UFCW L ONE:000038
file:////co-adshare/.../UFCW%20Local%20One%20Health%20Care%20Fund/UFCW%20Local%20One%20Approval%2012-30-2010.htm[11/15/2011 11:37:28 AM]
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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 disclosures may result in prosecution to the full extent of the law.
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UFCW L ONE:000039
file:////co-adshare/.../UFCW%20Local%20One%20Health%20Care%20Fund/UFCW%20Local%20One%20Approval%2012-30-2010.htm[11/15/2011 11:37:28 AM]
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UFCW L ONE:000040
UFCW L ONE:000041
From: andrea_goldberger@ufcwny.com Sent: Thursday, December 30, 2010 5:45 PM To: Habit, Sandra (HHS/OCIIO) Subject: Re: UFCW Local One Health Care Fund Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010 Dear Sandy, We are writing to acknowledge receipt of your email approving the waiver application for Plan M and the Retiree benefit provided by the UFCW Local One Health Care Fund. Thank you for your department's assistance and quick response. Happy New Year, Andrea Goldberger Sent from my Verizon Wireless Phone
Good Afternoon,
Retiree
Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance.
Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@hhs.gov<mailto:Sandra.Habit@hhs.gov>
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 disclosures may result in prosecution to the full extent of the law.
UFCW L ONE:000042
file:////co-adshare/...am/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Approval%20receipt%2012.30.10.htm[11/15/2011 11:37:30 AM]
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Sincerely
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Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for UFCW Local One Health Care Fund.. HHS has reviewed your application and made its determination. Please see the attached letter. The following plans have been approved: Plan M
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----- Reply message ----From: "Habit, Sandra (HHS/OCIIO)" <Sandra.Habit@hhs.gov> Date: Thu, Dec 30, 2010 4:15 pm Subject: UFCW Local One Health Care Fund Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010 To: "'andrea_goldberger@ufcwny.com'" <andrea_goldberger@ufcwny.com>
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UFCW L ONE:000043
file:////co-adshare/...am/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Approval%20receipt%2012.30.10.htm[11/15/2011 11:37:30 AM]
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From: Keels, Lisa (HHS/OCIIO) Sent: Monday, January 24, 2011 4:08 PM To: Andrews, Jane (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: FW: Your application for a waiver of annual limiits
Hi Jane, Please see below. Andrea confirmed that she received an approval letter from Sandy on 12/30. Im not sure about the G drive, but they were officially approved. Thanks, Lisa
From: Andrews, Jane (HHS/OCIIO) Sent: Tuesday, January 04, 2011 3:51 PM To: 'andrea_goldberger@ufcwny.com' Cc: Keels, Lisa (HHS/OCIIO); Habit, Sandra (HHS/OCIIO) Subject: 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 initial email from you, we thought it was a duplicate in error and did not respond I apologize for not contacting you sooner. We did receive a letter of approval from Sandra Habit on 12/30/10. Please let me know if you would like me to forward a copy of the email to you. Thank you and Happy New Year, Andrea Andrea D. Goldberger
UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424
UFCW L ONE:000044
file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Approval%20receipt%20confirmation%201.24.11.htm[11/15/2011 11:37:30 AM]
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From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com] Sent: Tuesday, January 04, 2011 3:24 PM To: Andrews, Jane (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
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I am glad you are all set. Thank you and happy new year to you. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)
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315-797-9600, ext 2253 Fax: 315-797-9664
From: Andrews, Jane (HHS/OCIIO) [mailto:Jane.Andrews@hhs.gov] Sent: Tuesday, January 04, 2011 3:28 PM To: 'Andrea_Goldberger@UFCWNY.com' Cc: Andrews, Jane (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
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 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. In order to complete your application, please provide this information by 5:00 pm, December 22, 2010. Once this
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From: Andrews, Jane (HHS/OCIIO) Sent: Monday, December 20, 2010 11:22 AM To: 'Andrea_Goldberger@UFCWNY.com' Subject: Your application for a waiver of annual limiits
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Please confirm that you received this e-mail from me. Thank you. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)
UFCW L ONE:000045
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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Please confirm that you received this e-mail from me. Thank you. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814
UFCW L ONE:000047
file:////co-adshare/...20Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Correspondence%201.4.11.htm[11/15/2011 11:37:31 AM]
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UFCW Local One Benefit Funds 5911 Airport Road Oriskany, NY 13424 315-797-9600, ext 2253 Fax: 315-797-9664
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301-492-4122 (desk) 202-536-6779 (Blackberry)
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 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. In order to complete your application, please provide this information by 5:00 pm, December 22, 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.

UFCW L ONE:000048
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file:////co-adshare/...Processing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Status%20update%201.24.11.htm[11/15/2011 11:37:31 AM]
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I think they were one we were duplicating efforts one. I have not been actively pursuing that ones completion, however, when I look at the folder for UFCW local district one, I dont see that they have been completed or approved. Can you please give a status update? Thanks! 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 24, 2011 3:58 PM To: Keels, Lisa (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: What Happened with UFCW Local district One?
Thank you! Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)
From: Andrews, Jane (HHS/OCIIO) Sent: Tuesday, January 25, 2011 8:20 AM To: Habit, Sandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
From: Habit, Sandra (HHS/OCIIO) Sent: Monday, January 24, 2011 4:41 PM To: Andrews, Jane (HHS/OCIIO); Keels, Lisa (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
The approval is in UFCW Local One Health Care Fund not UFCW District Union Local One. They appear to be duplicate files as
UFCW L ONE:000051
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Sandy - Would you be able to look at the original application and make a determination about its correct name (maybe Alex or Erica know its corrected name for the public list) and then consolidate the folders so we dont have dupes? 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) Sent: Monday, January 24, 2011 4:57 PM To: Habit, Sandra (HHS/OCIIO); Keels, Lisa (HHS/OCIIO) Cc: Pham, Erica (HHS/OCIIO); Botwinick, Alexandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
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I moved UFCW District Local One into UFCW Local One Health Care Fund. Sandy
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From: Habit, Sandra (HHS/OCIIO) Sent: Monday, January 24, 2011 5:13 PM To: Andrews, Jane (HHS/OCIIO); Keels, Lisa (HHS/OCIIO) Cc: Pham, Erica (HHS/OCIIO); Botwinick, Alexandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
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both folders contain correspondence to Andrea and the applications are identical. Sandy From: Andrews, Jane (HHS/OCIIO) Sent: Monday, January 24, 2011 4:13 PM To: Keels, Lisa (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits Sandy can you please check to see why their approval did not get on G Drive? Thanks a lot! Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)
From: Andrews, Jane (HHS/OCIIO) Sent: Tuesday, January 04, 2011 3:51 PM To: 'andrea_goldberger@ufcwny.com' Cc: Keels, Lisa (HHS/OCIIO); Habit, Sandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits I am glad you are all set. Thank you and happy new year to you. 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:

UFCW L ONE:000052
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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.
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:
UFCW L ONE:000053
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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 it 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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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 22, 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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UFCW L ONE:000054
From: Keels, Lisa (HHS/OCIIO) Sent: Monday, January 24, 2011 4:07 PM To: Andrews, Jane (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: What Happened with UFCW Local district One?
They were definitely approved in one of those meetings at the end of December. I believe they received an approval letter on December 30 th . I will forward you the email you forwarded me from Andrea Goldberger.
From: Andrews, Jane (HHS/OCIIO) Sent: Monday, January 24, 2011 3:58 PM To: Keels, Lisa (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: What Happened with UFCW Local district One?
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I think they were one we were duplicating efforts one. I have not been actively pursuing that ones completion, however, when I look at the folder for UFCW local district one, I dont see that they have been completed or approved. Can you please give a status update? Thanks! Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)
file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Status%20update%20correspondence%201.24.11.htm[11/15/2011 11:37:32 AM]
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Sandy can you please check to see why their approval did not get on G Drive? Thanks a lot! 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 24, 2011 4:13 PM To: Keels, Lisa (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
From: Andrea D Goldberger [mailto:andrea_goldberger@ufcwny.com]
UFCW L ONE:000056
file:////co-adshare/.../UFCW%20Local%20One%20Health%20Care%20Fund/Status%20update%20correspondence%20(2)%201.24.11.htm[11/15/2011 11:37:33 AM]
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Sent: Tuesday, January 04, 2011 3:24 PM To: Andrews, Jane (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
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
UFCW L ONE:000057
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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 it is, please provide the date the collective bargaining agreement will expire.
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UFCW L ONE:000058
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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 22, 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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Confirm that your plan is either self-insured or fully insured.
From: Habit, Sandra (HHS/OCIIO) Sent: Monday, January 24, 2011 4:41 PM To: Andrews, Jane (HHS/OCIIO); Keels, Lisa (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
The approval is in UFCW Local One Health Care Fund not UFCW District Union Local One. They appear to be duplicate files as both folders contain correspondence to Andrea and the applications are identical. Sandy From: Andrews, Jane (HHS/OCIIO) Sent: Monday, January 24, 2011 4:13 PM To: Keels, Lisa (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Your application for a waiver of annual limiits
I am glad you are all set. Thank you and happy new year to you. Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814
UFCW L ONE:000059
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Sandy can you please check to see why their approval did not get on G Drive? Thanks a lot! Jane W. Andrews OCIIO 7501 Wisconsin Ave Bethesda, MD 20814 301-492-4122 (desk) 202-536-6779 (Blackberry)
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301-492-4122 (desk) 202-536-6779 (Blackberry)
From: Andrews, Jane (HHS/OCIIO) Sent: Monday, December 20, 2010 11:22 AM To: 'Andrea_Goldberger@UFCWNY.com'
UFCW L ONE:000060
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Subject: Your application for a waiver of annual limiits
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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 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. In order to complete your application, please provide this information by 5:00 pm, December 22, 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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UFCW L ONE:000061

UFCW Local One - Redacted HWM

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From: Andrea D Goldberger [andrea_goldberger@ufcwny.

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

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

:TKE:kdM233.01 SMG:SES Enclosures cc:

D Arurv\</,L ftft/^ro /Rndrea D. Goldberger

(1) theFundwasin forceprior to September 23,2010;and

One Health Care Plan

I One Health Care Plan

Pages 8 through 155 redacted for the following reasons: ------------------------------------------------Exemption 4

file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.17.10.htm[11/15/2011 11:37:22 AM]

file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.17.10.htm[11/15/2011 11:37:22 AM]

file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.20.10.htm[11/15/2011 11:37:23 AM]

file:////co-adshare/...ocal%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20correspondence%2012.20.10.htm[11/15/2011 11:37:23 AM]

immediately by telephone at (202) 797-8700. Thank you.

The response is due by 5pm EST today.

file:////co-adshare/...ocal%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20correspondence%2012.20.10.htm[11/15/2011 11:37:23 AM]

file:////co-adshare/...ocal%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20correspondence%2012.20.10.htm[11/15/2011 11:37:23 AM]

file:////co-adshare/...ocal%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20correspondence%2012.20.10.htm[11/15/2011 11:37:23 AM]

ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name

Phone Number (including Zip Code area code)

UFCW Local One Health Care Fund

1-315-7979600, ext 2253

andrea_gold berger@ufcw ny.com Limited Benefit

UFCW Local One Health Care Fund

1-315-7979600, ext 2253

andrea_gold berger@ufcw ny.com Limited Benefit

PRA Disclosure Statement

ANNUAL LIMIT WAIVER APPLICATION 2010

Mental Health/ Substance Abuse

Office Visit Copays/Coinsurance

Hospital Inpatient Copay/Coinsurance

Emergency Room Copay/Coinsurance

ANNUAL LIMIT WAIVER APPLICATION 2010

Total $0.00 $0.00

Employee Employer contribution contribution (if applicable) (if applicable)

Total $0.00 $0.00

Employee Employer contribution contribution (if applicable) (if applicable)

Total $0.00 $0.00

Plan Administr ator/ CEO of Health Insurance Issuer Name

Title of Individual Providing Attestation

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file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2021.23.10.htm[11/15/2011 11:37:24 AM]

file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2021.23.10.htm[11/15/2011 11:37:24 AM]

file:////co-adshare/...ing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Reqeust%20for%20info%2012.23.10.htm[11/15/2011 11:37:25 AM]

II. In addition, please provide the following information:

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file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%2012.23.10.htm[11/15/2011 11:37:26 AM]

315-797-9600, ext 2253 Fax: 315-797-9664

file:////co-adshare/.../Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%2012.23.10.htm[11/15/2011 11:37:26 AM]

Thank you, Lisa

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file:////co-adshare/...0Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20clarification%2012.27.10.htm[11/15/2011 11:37:26 AM]

file:////co-adshare/...0Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20clarification%2012.27.10.htm[11/15/2011 11:37:26 AM]

file:////co-adshare/...0Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20clarification%2012.27.10.htm[11/15/2011 11:37:26 AM]

file:////co-adshare/...0Local%20One%20Health%20Care%20Fund/Request%20for%20info%20response%20clarification%2012.27.10.htm[11/15/2011 11:37:26 AM]

Happy New Year! Andrea

Sent from my Verizon Wireless Phone

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file:////co-adshare/...sing%20Team/Mike/UFCW%20Local%20One%20Health%20Care%20Fund/Request%20for%20info%2012.28.10.txt[11/15/2011 11:37:28 AM]

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4/6/2008-4/2/2011 4/27/2008-4/23/2011 8/3/2008-7/30/2011

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