Indiana Area UFCW - Redacted HWM

7/27/2019 Indiana Area UFCW - Redacted HWM

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//T|/...Union%20Locals%20and%20Retail%20Food%20Employers%20Health%20and%20Welfare%20Plan/Waiver%20application.htm[10/31/2011 3:06

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

ent: Wednesday, December 01, 2010 2:19 PM

o: HHS HealthInsurance (HHS); OCIIO Oversight

c: 'I. Mark Steckloff'

ubject: Waiver application

ttachments: 048001_ (v3) plan corr re application for waiver from annual benefit limits, w_exhs,

EXECUTED.PDF

ollow Up Flag: Follow up

lag Status: Completed

Dear Sir or Madam:

On behalf of the Indiana Area United Food and Commercial Workers Union Locals and Retailood Employers Health and Welfare Plan (the "Plan"), I attach correspondence and supportingocumentation regarding the Plan's application for waiver from restricted annual limits.

lease review the attached and respond at your earliest convenience. My e-mail address [email protected], and my direct phone number is 414-298-8279.

t is my understanding that the email inbox [email protected] may be full, and therefore I ending to both that email address [email protected] in order to ensure receipt.

Thank you for your attention to this matter.

William H. Tobin

einhart Boerner Van Deuren s.c.

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

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

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

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


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//T|/...als%20and%20Retail%20Food%20Employers%20Health%20and%20Welfare%20Plan/Request%20for%20info%2012.14.10.htm[10/31/2011 3:06

rom: Keels, Lisa (HHS/OCIIO)ent: Tuesday, December 14, 2010 5:20 PM

To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: Indiana Area UFCW Union Locans and Retail Food Employers Health and Welfare Plan Waiver ApplicaRequest for Additional Information

Attachments: Waiver Application Form.xlsx

Dear Mr. Tobin:

hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:

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

II. In addition, please provide the following information:

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

grandfathering provisions, pursuant to 45 CFR 147.140?

What is the date on which the last collective bargaining agreement(s) pursuant to which this plan was

negotiated will expire?

n order to complete your application, please provide this information by 5:00 pm, December 15, 2010. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you,isa Keels

sa M. Keels, J.D.

.S. Department of Health & Human Services

ffice of Consumer Information and Insurance Oversight

ffice of Oversight

[email protected]

01-492-4168

IN UFCW:000019


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//T|/...20Retail%20Food%20Employers%20Health%20and%20Welfare%20Plan/Request%20for%20info%20response%2012.15.10.htm[10/31/2011 3:06

rom: Keels, Lisa (HHS/OCIIO)ent: Wednesday, December 15, 2010 6:22 PM

To: William H. TobinCc: '[email protected]'; Habit, Sandra (HHS/OCIIO)ubject: RE: Indiana UFCW & Retail Food Ers Health&Welfare Plan | Waiver Application & Exh A & Annual Li

Waiver Application (HHS spreadsheet)hank you, Mr. Tobin. I will let you know if we have any questions.

est,sa

rom: Maire Mills Greenya [mailto:[email protected]] On Behalf OfWilliam H. Tobinent: Wednesday, December 15, 2010 5:03 PMo: Keels, Lisa (HHS/OCIIO)c: '[email protected]'ubject: Indiana UFCW & Retail Food Ers Health&Welfare Plan | Waiver Application & Exh A & Annual Limit Waiver ApplicationHHS spreadsheet)

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

lan's waiver application.

lease contact me with any questions or comments.

William H. Tobin

einhart Boerner Van Deuren s.c.

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

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

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

rom: Keels, Lisa (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, December 14, 2010 4:20 PMo: William H. Tobinc: Habit, Sandra (HHS/OCIIO)ubject: Indiana Area UFCW Union Locans and Retail Food Employers Health and Welfare Plan Waiver Application - Request fodditional Information

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

IN UFCW:000020
http://blocked:%3Amailto%[email protected]/http://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://reinhartlaw.com/http://reinhartlaw.com/http://reinhartlaw.com/http://www.reinhartlaw.com/People/Pages/vcard.aspx?who=wtobinhttp://www.reinhartlaw.com/People/Pages/bioredir.aspx?who=wtobinhttp://blocked:%3Amailto%[email protected]/


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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

randfathering provisions, pursuant to 45 CFR 147.140?

What is the date on which the last collective bargaining agreement(s) pursuant to which this plan was negotiate

will expire?

n order to complete your application, please provide this information by 5:00 pm, December 15, 2010. Once this

nformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you,isa Keelsisa M. Keels, J.D.

U.S. Department of Health & Human ServicesOffice of Consumer Information and Insurance OversightOffice of Oversight

[email protected]

01-492-4168

IN UFCW:000021
mailto:[email protected]:[email protected]


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ANNUAL L IMIT WAIVER APPLICATION 2010

Ann ual

imit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

App licant

(Plan/ Policy

Situs) City

App licant

(Plan/

Policy

Situs)

State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Add ress City State Zip Code

Phone

Number

(including

area code)

Email

Add ress

Type of

Coverage

(e.g., Limited

Benefit, HRA,

Rx only,

Other)

Self-

Insured

(Yes/No)

Indi

Grou

United Food

and

Commercial

WorkersRetail

Employees

and

Employers

Health and

Welfare Plan

Benefit

Packages A

and B

Pembroke

Pines FL 01/01/2011

Karin Peters,

National

Employees

Benefit

Administrator

s

2010 N.W.

150th Ave.,

Suite 100

Pembroke

Pines FL 33028

800-842-

5899

kpeters@neb

a-fl.com Limited Benefit Yes G

Limited

Benefit Option

Electrician

Helpers

Pembroke

Pines FL 01/01/2011

Karin Peters,

National

Employees

Benefit

Administrator

s

2010 N.W.

150th Ave.,

Suite 100

Pembroke

Pines FL 33028

800-842-

5899

kpeters@neb

a-fl.com Limited Benefit Yes G

Ivelisse BerioLeBeau,

Sugarman &

Susskind

100 Miracle

Mile, Suite

300 Coral Gables FL 33134 305-529-2801sugarmansusskind.com

PR Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours)


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or mnues per response, nc u ng e me o revew ns ruc ons, searc exs ng a a resources, ga er e a a nee e , an compe e an revew einformation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


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Amb ulat ory Emerg ency Hosp ital izati on Laborat ory Pediat ric

Maternity/

Newborn

Mental Health/

Substance

Abu se

Rehabilitative/

Devices

Preventive/

Wellness Prescription

Plan

Deductible

Current Essential Benefits Annual L imits (Annual Limit for Each Essential Benefit)


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.stop/loss insurance, as estimated above. Please see the written application for more information.

.


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Title of Individual

Providing

Att estat ion

Chairman of the

Board of Trustees

Chairman of the

Board of Trustees


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//T|/...0Locals%20and%20Retail%20Food%20Employers%20Health%20and%20Welfare%20Plan/Phone%20message%2012.20.10.htm[10/31/2011 3:06

rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 20, 2010 4:34 PM

To: Habit, Sandra (HHS/OCIIO)ubject: United Food and Commercial Workers Retail Employees and Employers Health and Welfare Plan Aeft message with plan administrator

am Lynne Moultrie


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

[email protected]

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribut

copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

IN UFCW:000030


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rom: Moultrie, Cam (HHS/OCIIO)ent: Tuesday, December 21, 2010 4:36 PM

To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health a

Welfare Plan Benefit Packages A and BDear Applicant:

hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information for eachenefit package:

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


Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with


Confirm whether your plan provides any lifetime limits.

Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and

expiration dates of the collective bargaining agreement.


hank you.

am Lynne Moultrie


.S. Department of Health and Human Services

301) 492-4174

[email protected]




IN UFCW:000031


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rom: Ivelisse Berio LeBeau [[email protected]]ent: Wednesday, December 22, 2010 7:58 PM

To: Moultrie, Cam (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and B

Attachments: UFCW 1625 A and B Waiver Application 11 22 10.pdf; UFCW 1625 Electricians Waiver Applicati

1 22 10.pdf; UFCW Retail EEs ERs Health Plan Spreadsheet 12 22 10.xlsCamattached is a completed spreadsheet in connection with the waiver applications for the UFCW Retailmployees and Employers Health and Welfare Plan. Please read the notes in the text boxes, which set forthelevant information describing the numbers in the spreadsheet.

he following information addresses your questions below. As further described in the written applications thlan is a multiemployer Taft-Hartley plan and the benefit packages for which waivers are sought are self-funde

The plan was in existence prior to March 23, 2010 and qualifies as a grandfathered plan. This plan has manyifferent employer groups that participate and there are just as many different collective bargaining agreement

CBAs) that require contributions to the Fund; the CBAs establish contributions to 2011, 2012 and 2013. Plannd B currently have a lifetime maximum benefit of $ and the electricians benefit package has a lifetim

maximum limit of $ . The lifetime limits will be eliminated as required under the ACA.lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.

lease let me know if you have any questions. Please note, however, that the written applications containasically all of the information that is on the spreadsheet, with the exception of the COBRA rate for the electricenefit package. Specific details about each of the CBAs including the effective and expiration dates of each onre not readily available given the short time period available to fashion this response. There is additionalnformation about the CBAs in the written applications, however, including information on the contribution rat

will be out of the office from December 22, 2010 to January 3, 2011, though I plan to check email during this t

eriod.

hanks for your anticipated attention and assistance. Happy holidays-- Ivelisse

velisse Berio LeBeau

ugarman & Susskind, PA00 Miracle Mileuite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)05-773-0043 (cell)

[email protected]

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, December 21, 2010 4:36 PMo: Ivelisse Berio LeBeauc: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfare Planenefit Packages A and B

Dear Applicant:

IN UFCW:000032
mailto:[email protected]://www.sugarmansusskind.com/http://www.sugarmansusskind.com/mailto:[email protected]


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

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








hank you.

am Lynne Moultrie



301) 492-4174

[email protected]




IN UFCW:000033


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//T|/...0Retail%20Food%20Employers%20Health%20and%20Welfare%20Plan/Request%20for%20addtional%20info%2012.23.10.htm[10/31/2011 3:06

rom: Ivelisse Berio LeBeau [[email protected]]ent: Thursday, December 23, 2010 12:57 PM

To: Keels, Lisa (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Hend Welfare Plan Benefit Packages A and B

Attachments: UFCW 1625 A and B Waiver Application 11 22 10.pdf; UFCW 1625 Electricians Waiver Applicati

1 22 10.pdf; UFCW Retail EEs ERs Health Plan Spreadsheet 12 22 10.xlsisa, Cam and Sandra-- Here is the email I sent to Cam last night with the requested additional information. Tring Cam up to date I received messages today from Lisa regarding the UFCW 1625 plan, but each of youeferenced only the Plan A and B application, not the mini-med for electricians. Please be sure that bothpplications are in the system! I included information on both in the attached spreadsheet and courtesy copieshe written applications.

know that your office has received a deluge of applications, and so far each of the reviewers Ive spoken to heen professional and helpful. I would greatly appreciate a prompt response on the UFCW 1625 applicationsecause my client is anxious to finalize arrangements for the coming plan year. I am out of the office untilanuary but am checking email and can respond to general questions. It might be challenging, however, to obdditional data or specific details over the next week or so.

hanks again for your assistance. I would greatly appreciate it if someone could respond to this email to confeceipt and confirm that both applications are in the final review process. Happy holidaysIvelisse



[email protected]

rom: Ivelisse Berio LeBeauent: Wednesday, December 22, 2010 7:58 PMo: 'Moultrie, Cam (HHS/OCIIO)'c: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B

Camattached is a completed spreadsheet in connection with the waiver applications for the UFCW Retail

mployees and Employers Health and Welfare Plan. Please read the notes in the text boxes, which set forthelevant information describing the numbers in the spreadsheet.




maximum limit of $ . The lifetime limits will of course be eliminated as required under the ACA.IN UFCW:000034


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lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.


will be out of the office from December 22, 2010 to January 3, 2011, though I plan to check email during this teriod.



ugarman & Susskind, PA00 Miracle Mileuite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)

05-773-0043 (cell)[email protected]

www.sugarmansusskind.com


Dear Applicant:








expiration dates of the collective bargaining agreement.IN UFCW:000035


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hank you.

am Lynne Moultrie



301) 492-4174

[email protected]




IN UFCW:000036


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//T|/...20Locals%20and%20Retail%20Food%20Employers%20Health%20and%20Welfare%20Plan/Response%20(2)%2012.23.10.htm[10/31/2011 3:06

rom: Keels, Lisa (HHS/OCIIO)ent: Thursday, December 23, 2010 1:50 PM

To: Ivelisse Berio LeBeauCc: Pham, Erica (HHS/OCIIO); Moultrie, Cam (HHS/OCIIO); Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and Bhank you, Ivelisse. And thank you for cooperating with us. Just to clarify, the information provided on the spreadsheet

ttached to your email contains information for Plans A&B, as well as information for the limited benefit plan for electricia

orrect?

hank you for sending us both applications. We will process these and respond to you as quickly as possible.

appy holidays,

sa

rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Thursday, December 23, 2010 12:57 PMo: Keels, Lisa (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)

ubject: FW: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfarean Benefit Packages A and B

isa, Cam and Sandra-- Here is the email I sent to Cam last night with the requested additional information. Tring Cam up to date I received messages today from Lisa regarding the UFCW 1625 plan, but each of youeferenced only the Plan A and B application, not the mini-med for electricians. Please be sure that bothpplications are in the system! I included information on both in the attached spreadsheet and courtesy copieshe written applications.

know that your office has received a deluge of applications, and so far each of the reviewers Ive spoken to heen professional and helpful. I would greatly appreciate a prompt response on the UFCW 1625 applicationsecause my client is anxious to finalize arrangements for the coming plan year. I am out of the office until

anuary but am checking email and can respond to general questions. It might be challenging, however, to obdditional data or specific details over the next week or so.



ugarman & Susskind, PA00 Miracle Mileuite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)05-773-0043 (cell)[email protected]



IN UFCW:000037


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Camattached is a completed spreadsheet in connection with the waiver applications for the UFCW Retailmployees and Employers Health and Welfare Plan. Please read the notes in the text boxes, which set forthelevant information describing the numbers in the spreadsheet.




maximum limit of $ The lifetime limits will be eliminated as required under the ACA.lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.

lease let me know if you have any questions. Please note, however, that the written applications containasically all of the information that is on the spreadsheet, with the exception of the COBRA rate for the electricenefit package. Specific details about each of the CBAs including the effective and expiration dates of each onre not readily available given the short time period available to fashion this response. There is additional

nformation about the CBAs in the written applications, however, including information on the contribution rat




ugarman & Susskind, PA00 Miracle Mileuite 300oral Gables, FL 33134

05-529-2801 (main line)05-447-8115 (fax)05-773-0043 (cell)[email protected]



Dear Applicant:


I. Please complete the entire annual limits spreadsheet available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheto this email address as an attachment. We will only be able to process spreadsheets that are fully comp

IN UFCW:000038


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(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain tyour plan, please write None, and/or provide an explanation regarding why you are unable to completethat particular cell in a separate document.








hank you.

am Lynne Moultrie



301) 492-4174

[email protected]




IN UFCW:000039


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rom: Keels, Lisa (HHS/OCIIO)ent: Thursday, December 23, 2010 3:25 PM

To: [email protected]: Moultrie, Cam (HHS/OCIIO); Pham, Erica (HHS/OCIIO); Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial WorkersRetail Employees and Employers Heand Welfare Plan Benefit Packages Aand Breat, thanks so much, Ivelisse. Cam will continue to work with you on the application for Plans A and B, and I will work o

he Helper Electricians application.

hank you again, and happy holidays,

sa

rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Thursday, December 23, 2010 3:19 PMo: Keels, Lisa (HHS/OCIIO)ubject: Re: Waiver Application for United Food and Commercial WorkersRetail Employees and Employers Health and Welfare enefit Packages Aand B

included all benefit packages in one spreadsheet. There is one application for Plans A and B and one application he helper electricians. Thanks for your help-- Ivelisse

velisse Berio LeBeau05-773-0043 cell 305-529-2801 office

rom: "Keels, Lisa (HHS/OCIIO)" Date: Thu, 23 Dec 2010 13:49:49 -0500To: Ivelisse Berio LeBeauCc: Pham, Erica (HHS/OCIIO); Moultrie, Cam(HHS/OCIIO);Habit, Sandra (HHS/OCIIO)

ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and B

hank you, Ivelisse. And thank you for cooperating with us. Just to clarify, the information provided on the spreadsheet

ttached to your email contains information for Plans A&B, as well as information for the limited benefit plan for electricia

orrect?

hank you for sending us both applications. We will process these and respond to you as quickly as possible.

appy holidays,

sa

rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Thursday, December 23, 2010 12:57 PMo: Keels, Lisa (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfarean Benefit Packages A and B

isa, Cam and Sandra-- Here is the email I sent to Cam last night with the requested additional information. Tring Cam up to date I received messages today from Lisa regarding the UFCW 1625 plan, but each of youeferenced only the Plan A and B application, not the mini-med for electricians. Please be sure that both

IN UFCW:000040


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pplications are in the system! I included information on both in the attached spreadsheet and courtesy copieshe written applications.

know that your office has received a deluge of applications, and so far each of the reviewers Ive spoken to heen professional and helpful. I would greatly appreciate a prompt response on the UFCW 1625 applicationsecause my client is anxious to finalize arrangements for the coming plan year. I am out of the office untilanuary but am checking email and can respond to general questions. It might be challenging, however, to obdditional data or specific details over the next week or so.






Camattached is a completed spreadsheet in connection with the waiver applications for the UFCW Retailmployees and Employers Health and Welfare Plan. Please read the notes in the text boxes, which set forth

elevant information describing the numbers in the spreadsheet.




maximum limit of $ . The lifetime limits will be eliminated as required under the ACA.lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.



IN UFCW:000041


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Dear Applicant:










hank you.

am Lynne Moultrie


IN UFCW:000042


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301) 492-4174

[email protected]




IN UFCW:000043


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rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 27, 2010 4:35 PM

To: Ivelisse Berio LeBeauCc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and Bhank you for the information.

m I to assume that the benefits are the same where you have not indicated Plan A or Plan B?re the contribution rates the same for plans A and B?

ou mention there are individuals. How many are in plan A? How many are in plan B?

or plans A and B you stated that the values given approximate the cost per employee. Do employees make contribution

am Lynne Moultrie



301) 492-4174

[email protected]




rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Wednesday, December 22, 2010 7:58 PMo: Moultrie, Cam (HHS/OCIIO)

c: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B





maximum limit of $ . The lifetime limits will of course be eliminated as required under the ACA.lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.

lease let me know if you have any questions. Please note, however, that the written applications containasically all of the information that is on the spreadsheet, with the exception of the COBRA rate for the electricenefit package. Specific details about each of the CBAs including the effective and expiration dates of each onre not readily available given the short time period available to fashion this response. There is additional

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nformation about the CBAs in the written applications, however, including information on the contribution rat




ugarman & Susskind, PA

00 Miracle Mileuite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)05-773-0043 (cell)[email protected]



Dear Applicant:


I. Please complete the entire annual limits spreadsheet available at:

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








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hank you.

am Lynne Moultrie



301) 492-4174

[email protected]




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rom: Ivelisse Berio LeBeau [[email protected]]ent: Tuesday, December 28, 2010 1:12 PM

To: Moultrie, Cam (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and B

Hello Cam. In the spreadsheet I squeezed in as much info as possible on the different co-pays, co-insurance, edentifying the differences between the two plan options; the full info is included in the schedules of benefits

ttached to the written application as exhibits. If I didnt specify a difference then there isnt one for the categosted in the spreadsheet. Generally the benefits are more expansive under the Plan A option than the Plan Bption, and the contribution rates are different as well. The contribution rates are established under each CBAeflecting various conditions including the size of the group, the level of employee contributions, the amount omployer contributions, whether or not family coverage is available, the type of benefits negotiated in collectivargaining and required under the CBAs; contribution rates are higher for better benefit packages. Some of th

CBAs reflect negotiations for enhanced benefits; for example there are two Plan A and two Plan B versionseflecting negotiated differences in benefits. All of the CBAs for the nursing home employees include some levf employee contributions towards coverage, and the employee contribution rate is set by contract along with tmployer contribution rate. Some employees are allowed to include their families in coverage if they self-pay dditional contributions for family coverage.

n the spreadsheet the premium numbers for the nursing home employees plan reflect anticipated costs for toming plan year, not contribution rates. Contribution rates, both employer and employee, will remain the samegardless of increased costs because they are established contractually. As is typical in multiemployer plans cre estimated on a per employee basis, where the employee and his dependents are treated as one unit. Thestimated per capita costs for plan year 2011 thus include costs for all persons covered under the plan averagedased on the number of employees.

he breakdown on persons covered under Plans A and B is in the written application. Using actual numbers asOctober 31, 2010 there were employees and dependents covered under both plans, including employ

nd dependents under Plan B and employees with dependents under Plan A.hope this answers your questions. I am out of the office this week but checking email occasionally. Please le

me know if you have any additional questions and Ill do my best to answer them for you remotely! Thanksvelisse



[email protected]

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Monday, December 27, 2010 4:35 PMo: Ivelisse Berio LeBeauc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B

hank you for the information.

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m I to assume that the benefits are the same where you have not indicated Plan A or Plan B?

re the contribution rates the same for plans A and B?

ou mention there are individuals. How many are in plan A? How many are in plan B?or plans A and B you stated that the values given approximate the cost per employee. Do employees make contribution

am Lynne Moultrie


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

[email protected]




rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Wednesday, December 22, 2010 7:58 PMo: Moultrie, Cam (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B





maximum limit of $ The lifetime limits will of course be eliminated as required under the ACA.lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.




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Dear Applicant:

hank 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 for eachenefit package:








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

nformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you.

am Lynne Moultrie



301) 492-4174

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[email protected]




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rom: Moultrie, Cam (HHS/OCIIO)ent: Wednesday, December 29, 2010 1:59 PM

To: Ivelisse Berio LeBeauCc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and Bre the plans in compliance with the grandfather regulations?

it a Taft Hartley Plan? If so, what is the effective and expiration date of the CBA?

am Lynne Moultrie



301) 492-4174

[email protected]




rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Tuesday, December 28, 2010 1:12 PMo: Moultrie, Cam (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B

Hello Cam. In the spreadsheet I squeezed in as much info as possible on the different co-pays, co-insurance, edentifying the differences between the two plan options; the full info is included in the schedules of benefitsttached to the written application as exhibits. If I didnt specify a difference then there isnt one for the categosted in the spreadsheet. Generally the benefits are more expansive under the Plan A option than the Plan Bption, and the contribution rates are different as well. The contribution rates are established under each CBAeflecting various conditions including the size of the group, the level of employee contributions, the amount omployer contributions, whether or not family coverage is available, the type of benefits negotiated in collectivargaining and required under the CBAs; contribution rates are higher for better benefit packages. Some of th

CBAs reflect negotiations for enhanced benefits; for example there are two Plan A and two Plan B versionseflecting negotiated differences in benefits. All of the CBAs for the nursing home employees include some levf employee contributions towards coverage, and the employee contribution rate is set by contract along with t

mployer contribution rate. Some employees are allowed to include their families in coverage if they self-pay dditional contributions for family coverage.

n the spreadsheet the premium numbers for the nursing home employees plan reflect anticipated costs for toming plan year, not contribution rates. Contribution rates, both employer and employee, will remain the samegardless of increased costs because they are established contractually. As is typical in multiemployer plans cre estimated on a per employee basis, where the employee and his dependents are treated as one unit. Thestimated per capita costs for plan year 2011 thus include costs for all persons covered under the plan averagedased on the number of employees.

he breakdown on persons covered under Plans A and B is in the written application. Using actual numbers as

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October 31, 2010 there were employees and dependents covered under both plans, including employnd dependents under Plan B and emplo es with dependents under Plan A.hope this answers your questions. I am out of the office this week but checking email occasionally. Please le



ugarman & Susskind, PA

00 Miracle Mileuite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)05-773-0043 (cell)[email protected]


rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Monday, December 27, 2010 4:35 PMo: Ivelisse Berio LeBeauc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B



re the contribution rates the same for plans A and B?

ou mention there are individuals. How many are in plan A? How many are in plan B?or plans A and B you stated that the values given approximate the cost per employee. Do employees make contribution

am Lynne Moultrie



301) 492-4174

[email protected]





Camattached is a completed spreadsheet in connection with the waiver applications for the UFCW RetailIN UFCW:000052


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mployees and Employers Health and Welfare Plan. Please read the notes in the text boxes, which set forthelevant information describing the numbers in the spreadsheet.




maximum limit of $ The lifetime limits will of course be eliminated as required under the ACA.lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.





ugarman & Susskind, PA00 Miracle Mileuite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)

05-773-0043 (cell)[email protected]


Dear Applicant:


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

IN UFCW:000053


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that particular cell in a separate document.








hank you.

am Lynne Moultrie



301) 492-4174

[email protected]




IN UFCW:000054


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rom: Moultrie, Cam (HHS/OCIIO)ent: Wednesday, December 29, 2010 4:17 PM

To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for United Food and Commercial WorkersRetail Employees and Employers Heand Welfare Plan Benefit Packages Aand B

am Lynne Moultrie

ffice of Consumer Information and Insurance Oversight.S. Department of Health and Human Services

301) 492-4174

[email protected]




rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Wednesday, December 29, 2010 3:45 PMo: Moultrie, Cam (HHS/OCIIO)ubject: Re: Waiver Application for United Food and Commercial WorkersRetail Employees and Employers Health and Welfare enefit Packages Aand B

Yes, the plan is grandfathered. There are multiple CBAs that go through 2011, 2012, and 2013 and were in effect po March 2010. Thanks- Ivelisse


05-773-0043 cell 305-529-2801 office

rom: "Moultrie, Cam (HHS/OCIIO)" Date: Wed, 29 Dec 2010 13:58:31 -0500To: Ivelisse Berio LeBeauCc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Heand Welfare Plan Benefit Packages A and B

re the plans in compliance with the grandfather regulations?

it a Taft Hartley Plan? If so, what is the effective and expiration date of the CBA?

am Lynne Moultrie



301) 492-4174

[email protected]

IN UFCW:000055


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rom: Ivelisse Berio LeBeau [mailto:[email protected]]ent: Tuesday, December 28, 2010 1:12 PM

o: Moultrie, Cam (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B

Hello Cam. In the spreadsheet I squeezed in as much info as possible on the different co-pays, co-insurance, edentifying the differences between the two plan options; the full info is included in the schedules of benefitsttached to the written application as exhibits. If I didnt specify a difference then there isnt one for the categosted in the spreadsheet. Generally the benefits are more expansive under the Plan A option than the Plan Bption, and the contribution rates are different as well. The contribution rates are established under each CBAeflecting various conditions including the size of the group, the level of employee contributions, the amount omployer contributions, whether or not family coverage is available, the type of benefits negotiated in collectiv

argaining and required under the CBAs; contribution rates are higher for better benefit packages. Some of thCBAs reflect negotiations for enhanced benefits; for example there are two Plan A and two Plan B versionseflecting negotiated differences in benefits. All of the CBAs for the nursing home employees include some levf employee contributions towards coverage, and the employee contribution rate is set by contract along with tmployer contribution rate. Some employees are allowed to include their families in coverage if they self-pay dditional contributions for family coverage.

n the spreadsheet the premium numbers for the nursing home employees plan reflect anticipated costs for toming plan year, not contribution rates. Contribution rates, both employer and employee, will remain the samegardless of increased costs because they are established contractually. As is typical in multiemployer plans cre estimated on a per employee basis, where the employee and his dependents are treated as one unit. The

stimated per capita costs for plan year 2011 thus include costs for all persons covered under the plan averagedased on the number of employees.

he breakdown on persons covered under Plans A and B is in the written application. Using actual numbers asOctober 31, 2010 there were employees and dependents covered under both plans, including employ

nd dependents under Plan B and employees with dependents under Plan A.hope this answers your questions. I am out of the office this week but checking email occasionally. Please le





rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]IN UFCW:000056


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ent: Monday, December 27, 2010 4:35 PMo: Ivelisse Berio LeBeauc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health and Welfareenefit Packages A and B



re the contribution rates the same for plans A and B?ou mention there are individuals. How many are in plan A? How many are in plan B?

or plans A and B you stated that the values given approximate the cost per employee. Do employees make contribution

am Lynne Moultrie



301) 492-4174

[email protected]








CBAs) that require contributions to the Fund; the CBAs establish contributions to 2011, 2012 and 2013. Plan

nd B currently have a lifetime maximum benefit of $ and the electricians benefit package has a lifetimmaximum limit of $ . The lifetime limits will be eliminated as required under the ACA.

lease note that there were two different applications filed for different benefit packages. For your conveniencttached copies of the written applications that had been filed on November 22, 2010.


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ugarman & Susskind, PA00 Miracle Mile

uite 300oral Gables, FL 3313405-529-2801 (main line)05-447-8115 (fax)05-773-0043 (cell)[email protected]


rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, December 21, 2010 4:36 PMo: Ivelisse Berio LeBeauc: Habit, Sandra (HHS/OCIIO)

ubject: Waiver Application for United Food and Commercial Workers Retail Employees and Employers Health an

Indiana Area UFCW - Redacted HWM

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