7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 116

T|20Local20300WAIVER--SEIU20Local2030020Civil20Service20Forum20Employees20Welfare20Fundhtm[08122011 440

rom Gogna Anubhav (AGognagroomcom) [AGognagroomcom]ent Monday November 22 2010 106 PM

To HHS HealthInsurance (HHS)Cc Mazawey Lou (ltmgroomcom) Nielsen Mark (mcngroomcom) Killion Tammy (TKilliongroomcomubject WAIVER--SEIU Local 300 Civil Service Forum Employees Welfare Fund

Attachments SEIU Local 300 Welfare Fund Waiver--FINALdocpdf

ear Mr Mayhew

n behalf of the SEIU Local 300 Civil Service Forum Employees Welfare Fund (the Fund) I am submitting this application foaiver of the restricted annual limit under Public Health Services Act sect 2711 pursuant to OCIIO Sub-Reg y Guidance OC010-1 and 2010-1A The Fund has a per-covered person annual limit on prescription drug benefits of $ and as detaile

he attached waiver application imposition of a $750000 annual limit would result in the Funds insolvency or drastically reducccess to benefits for those currently covered by the Fund

We appreciate your consideration of the Funds request Please let Lou Mazawey Mark Nielsen or me know if you have anyuestions or need anything else Lou can be reached at 2028616608 Mark can be reached at at 2028615429 and I can beeached at 2028612602

est regards

nubhav Gogna

01947006]

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

otice This message is intended only for use by the person or entity to which it is addressed Because it may contain confidenformation intended solely for the addressee you are notified that any disclosing copying downloading distributing or retainin

his message and any attached files is prohibited and may be a violation of state or federal law If you received this message rror please notify the sender by reply mail and delete the message and all attached files

o comply with US Treasury Regulations we also inform you that unless expressly stated otherwise any tax advice containehis communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenode and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres this communication

SEIU L300000001

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 216

SEIU LOCAL 300 CIVIL SERVICE FORUMACTIVE EMPLOYEES W ELFARE FUND

36-36 33trade STREET SUITE 200Long Island City NY 11106

(718) 383-8945

November 192010

V ia Electronic Delivery healthinsurancerahhsgov

Mr James MayhewOffice of OversightmdashOffice of Consumer Information and Insurance OversightUS Department of Health an d Human ServicesRoom 737-F-04200 Independence Avenue SWWashington DC 20201

RE W aiver Requestmdash SEIU Local 300 - Civil Service Forum Employees W elfareFund

Employer Identification Num ber 13-6167915

Dear Mr Mayhew

The SEIU L ocal 300 Civil Service Forum Employees Welfare Fund (the Fund)respectfully submits this application fo r waiver of the restricted annual limits se t forth inthe Department of Health and Human Services Interim Final Rule (the IFR) issued onJune 28 2010 (75 Fed Reg 3718 8) prom ulgated pursuant to the Patient Protection andAffordable Care Act (the ACA) The Funds next Plan Year begins January 1 2011and we therefore request that the Department review and approve this waiver applicationin accordance with the Sub-Regulatory Guidance (OCIIO 2010-1 an d OCIIO 2010-1 A)issued by the Office of Consumer Information and Insurance O versight (OC IIO) onSeptember 3 2010 and Novem ber 5 2010 respectively

Pursuant to O CIIO s Sub-Regulatory Gu idance the Fund subm its the followinginformation

1 The Terms of the Plan fo r Which the Waiver Is Sought

This waiver application is submitted on behalf of the Fund a self-funded plan thatprovides supplemental benefits to employees of the City of New York in over 40 jobtitles who are covered under a collective bargaining agreement (CBA ) between theSEIU Local 300 Civil Service Forum (the U nion) and New York Cit hom theCity makes contributions to the Fund The Fund covers approximatelyparticipants which includes covered employees an d their eligible dependents The Fundprovides presc ription drug dental vision hearing aid disability death an d other

SEIU L300000002

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 316

supplemental ben efits not provided by the City of New York to Fund m embers and theireligible dependents The Funds participants and eligible dependen ts receive health-related coverage (eg prescription drugs dental vision and hearing aid bene fits) withminimal copayments The Funds m embers may access dental and vision benefitsthrough preferred provider networks that accept the Funds benefit schedules with little tono out-of-pocket cost to the m ember or members may see out-of-network providers oftheir choice and seek direct reimbursement from the Fund Basic health plans providedby New York C ity do not include prescription drug coverage and the other benefitsoffered by the Fund As a consequence most union sponsored supplemental benefitplans such as those prov ided by the Fu nd fill these critical gaps in coverage typicallywith prudently established annual limits Some of the benefits provided by the Fund arenot subject to the ACAs restricted annual limits How ever the essential ben efitsprovided by the Fund are currently subject to annual limits that are well below the$750000 restricted annual limit established b y the IF R for Plan Years beginning on orafter September 23 2010 but before September 23 2011 For these benefits we believethat a waiver is warranted

2 Number of Individuals Covered

The Fund currently provides coverage to m ore than participants anddependents

3 The Annual Limits and Rates Applicable to the Plan

The Fund has a $ annual limit per covered person on prescription drugcoverage

The City of New York contributes $ pe r employeeper annum to the Fund

which is applied to co ver the cost of all Fund benefits and administrative costs Thecontribution rate is established pursuant to a CBA between the Union and the City ofNew York Fund memb ers and their eligible dependents do not pay a premium orotherwise contribute direc tly to the Fun d for access to coverage although they do paymodest co-payments for various covered benefits and have access to the Funds dentalfacility at no charge W ith respect to the Funds prescription drug cove rage there is athree tier copayment structure fo r prescription drugs that are dispensed by participatingnetwork pharmacies $ fo r generic drugs $ for preferred brand name drugs and $ for non-preferred brand name drugs Fund participants that receive prescription drugsfrom out-of-network pharmacies are reimbursed directly in accordance with a feeschedule established by the Fund

4 Description of Why Com pliance W ith the IFR W ould Result In aDecrease in Access to Benefits Or a Significant Premium Increase

The benef its provided by the Fund are collectively bargained between the U nionand New York C ity and are the result of hard-fought negotiations which contractuallyobligate New York C ity to remit the negotiated contribution rate to the Fund The Citys

SEIU L300000003

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 416

contributions to the Fund are limited by contract and must cover all benefits provided bythe Fund The current CBA w ith the City will expire in March 2011

The Funds consultant has calculated the impact that raising the Funds annuallimits to $750000 wou ld have on the Fund Currently New York City contributes$ per member annually to the Fund which is used to fund all of the benefits offeredby t nd including prescription drug coverage The Fund currently pays a maximumo annua lly per covered person for prescription drugs Even w ith a limit as low as$ per year the Fund spends more than one-third of New York Citys annualcontributions on prescription drug costs alone The Fund cann ot remain solvent if it werer to raise its annual limits on prescription drug benefits from $ to $750000 -

a percent increase Indeed given that the Funds resources are severely limited -

an d because contributions rates are contractually established through a CBA that wasnegotiated long before the ACA s enactment - a percent increase in annual limitswill force the Fund to discontinue or drastically diminish offering various benefitsincluding prescription drug coverage

Further the Funds consultant estimates that implementing the $750000 annuallimit between January 1 2011 and December 31 2011 would n a conservative increase the Fun ds prescription drug costs by ap proximately percent (over $ )and result in financial insolvency absent additional funding of which there is none

According to the Funds consultant it is expected that removal of the Funds annualprescription drug maximum will cause prescription drug costs to eventually reach to times ($ to $ over the current levels This woul uire the Unionto obtain an incre e in New York Citys contribution rate of almost percent(approximately $ per covered employee per year) simply to cover the Funds additionalbenefit expenditures fo r prescription drugs during the 2011 Plan Year A contributionrate increase is not possible how ever given that New York Citys contribution rate is

contractually established in a CBA Accordingly there is no way for the Fund to obtain acontribution rate that wo uld sustain benefits offered with a $750000 an nual limit and toprevent insolvency the Funds Trustees would be forced to either cut the Fundsprescription drug benefits or to reduce other critical benefits that the Fund offers such asdental an d vision to offset the additional costs that will result from a $750000 annuallimit during the 2011 plan year Un der either scenario Fund mem bers would experiencea significant decrease in access to benefits fo r those currently covered by the [Fund]

which is what O CIIOs guidance requires fo r issuance of a waiver Se e September 32010 guidance sectIII(4)-(5)

Based on the above information we respectfully request a waiver of the $750000

restricted ann ual limit for the Plan Year commenc ing January 1 2011

5 Attestation

By m y signature below I certify that th e coverage provided by the Fund was inforce prior to September 23 2010 and that application o f the restricted a nnual limits tothe Fund for the January 1 2011 -December 31 2011 Plan Year would result in the

SEIU L300000004

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 516

Fun ds insolvency and thus a significant decrease in access to if not the total eliminationof benefits for those currently covered by the Fund

W e very much appreciate the Departments consideration of this waiverapplication and we look forward to hearing from you In the meantime please do not

hesitate to contact the Funds legal counsel Louis T Mazawey Mark C Nielsen orAnubhav Gogna should you have any qu estions or require any additional informa tionMr Mazawey may be reached at 2028616608 or by email at ltm groom com MrNielsen may be reached at 2028615429 or by email at mcngroomcom and MrGogna may be reached at 2028612602 or by email at agognagroomcom

James D GoldenChairman SEIU Local 300 Civil ServiceForum Welfare Fund

SEIU L300000005

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 616

T|rvice20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Request20Dec209202010htm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Thursday December 09 2010 229 PM

o Sheer Jennifer (HHSOCIIO)

ubject FW SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver

Request (01947006)

ttachments SEIU Local 300 Fund Waiver Spreadsheetxls

oe Records

301) 492-4257

rom Gogna Anubhav ( AGognagroomcom) [mailtoAGognagroomcom] ent Thursday December 09 2010 951 AMo Records Joseph (HHSOCIIO)c Mazawey Lou (ltmgroomcom) Nielsen Mark (mcngroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request (01947006)

ear Mr Records

hank you for your email regarding the annual limit waiver request that was filed by the SEIU Local 300 Civil Service Forummployees Welfare Fund (the Fund) As requested we are attaching the spreadsheet that your office provided detailing

formation applicable to the Funds prescription drug benefits for which the Fund has requested a waiver of the annual limit th

urrently in effect

n response to your specific questions please note

As detailed in the Funds attestation that accompanied its waiver request the Fund was in existence prior to March 23 20

The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147140 and

The Fund is not established pursuant to the Taft-Hartley Act which applies only to benefit plans that are jointly maintained

nions and employers and which are governed by a joint board of trustees comprising an equal number of employer and union

ustees Rather the Fund was established and is maintained by the SEIU Local 300 Civil Service Forum (the Union) to provupplemental benefits -- such as prescription drug coverage -- to collectively bargained employees of New York City who are

epresented by the Union The supplemental benefits provided by the Fund (prescription drug dental vision hearing aid and

eath) are not covered by the City of New Yorks plan for such employees Accordingly the Union established the Fund to fill

his gap in coverage and to ensure that collectively bargained employees receive coverage for these important health benefits

he Fund provides these benefits with contributions from the City negotiated between the Union and the City

hope this information is helpful If you have any questions or need anything else please contact Mark Nielsen or me Mark c

e reached at 2028615429 and I can be reached at 2028612602

est regards

nubhav Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Records Joseph (HHSOCIIO) [mailtoJosephRecordshhsgov] ent Wednesday December 08 2010 514 PMo Gogna Anubhav ( AGognagroomcom)c Sheer Jennifer (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request

SEIU L300000006

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 316

supplemental ben efits not provided by the City of New York to Fund m embers and theireligible dependents The Funds participants and eligible dependen ts receive health-related coverage (eg prescription drugs dental vision and hearing aid bene fits) withminimal copayments The Funds m embers may access dental and vision benefitsthrough preferred provider networks that accept the Funds benefit schedules with little tono out-of-pocket cost to the m ember or members may see out-of-network providers oftheir choice and seek direct reimbursement from the Fund Basic health plans providedby New York C ity do not include prescription drug coverage and the other benefitsoffered by the Fund As a consequence most union sponsored supplemental benefitplans such as those prov ided by the Fu nd fill these critical gaps in coverage typicallywith prudently established annual limits Some of the benefits provided by the Fund arenot subject to the ACAs restricted annual limits How ever the essential ben efitsprovided by the Fund are currently subject to annual limits that are well below the$750000 restricted annual limit established b y the IF R for Plan Years beginning on orafter September 23 2010 but before September 23 2011 For these benefits we believethat a waiver is warranted

2 Number of Individuals Covered

The Fund currently provides coverage to m ore than participants anddependents

3 The Annual Limits and Rates Applicable to the Plan

The Fund has a $ annual limit per covered person on prescription drugcoverage

The City of New York contributes $ pe r employeeper annum to the Fund

which is applied to co ver the cost of all Fund benefits and administrative costs Thecontribution rate is established pursuant to a CBA between the Union and the City ofNew York Fund memb ers and their eligible dependents do not pay a premium orotherwise contribute direc tly to the Fun d for access to coverage although they do paymodest co-payments for various covered benefits and have access to the Funds dentalfacility at no charge W ith respect to the Funds prescription drug cove rage there is athree tier copayment structure fo r prescription drugs that are dispensed by participatingnetwork pharmacies $ fo r generic drugs $ for preferred brand name drugs and $ for non-preferred brand name drugs Fund participants that receive prescription drugsfrom out-of-network pharmacies are reimbursed directly in accordance with a feeschedule established by the Fund

4 Description of Why Com pliance W ith the IFR W ould Result In aDecrease in Access to Benefits Or a Significant Premium Increase

The benef its provided by the Fund are collectively bargained between the U nionand New York C ity and are the result of hard-fought negotiations which contractuallyobligate New York C ity to remit the negotiated contribution rate to the Fund The Citys

SEIU L300000003

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 416

contributions to the Fund are limited by contract and must cover all benefits provided bythe Fund The current CBA w ith the City will expire in March 2011

The Funds consultant has calculated the impact that raising the Funds annuallimits to $750000 wou ld have on the Fund Currently New York City contributes$ per member annually to the Fund which is used to fund all of the benefits offeredby t nd including prescription drug coverage The Fund currently pays a maximumo annua lly per covered person for prescription drugs Even w ith a limit as low as$ per year the Fund spends more than one-third of New York Citys annualcontributions on prescription drug costs alone The Fund cann ot remain solvent if it werer to raise its annual limits on prescription drug benefits from $ to $750000 -

a percent increase Indeed given that the Funds resources are severely limited -

an d because contributions rates are contractually established through a CBA that wasnegotiated long before the ACA s enactment - a percent increase in annual limitswill force the Fund to discontinue or drastically diminish offering various benefitsincluding prescription drug coverage

Further the Funds consultant estimates that implementing the $750000 annuallimit between January 1 2011 and December 31 2011 would n a conservative increase the Fun ds prescription drug costs by ap proximately percent (over $ )and result in financial insolvency absent additional funding of which there is none

According to the Funds consultant it is expected that removal of the Funds annualprescription drug maximum will cause prescription drug costs to eventually reach to times ($ to $ over the current levels This woul uire the Unionto obtain an incre e in New York Citys contribution rate of almost percent(approximately $ per covered employee per year) simply to cover the Funds additionalbenefit expenditures fo r prescription drugs during the 2011 Plan Year A contributionrate increase is not possible how ever given that New York Citys contribution rate is

contractually established in a CBA Accordingly there is no way for the Fund to obtain acontribution rate that wo uld sustain benefits offered with a $750000 an nual limit and toprevent insolvency the Funds Trustees would be forced to either cut the Fundsprescription drug benefits or to reduce other critical benefits that the Fund offers such asdental an d vision to offset the additional costs that will result from a $750000 annuallimit during the 2011 plan year Un der either scenario Fund mem bers would experiencea significant decrease in access to benefits fo r those currently covered by the [Fund]

which is what O CIIOs guidance requires fo r issuance of a waiver Se e September 32010 guidance sectIII(4)-(5)

Based on the above information we respectfully request a waiver of the $750000

restricted ann ual limit for the Plan Year commenc ing January 1 2011

5 Attestation

By m y signature below I certify that th e coverage provided by the Fund was inforce prior to September 23 2010 and that application o f the restricted a nnual limits tothe Fund for the January 1 2011 -December 31 2011 Plan Year would result in the

SEIU L300000004

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 516

Fun ds insolvency and thus a significant decrease in access to if not the total eliminationof benefits for those currently covered by the Fund

W e very much appreciate the Departments consideration of this waiverapplication and we look forward to hearing from you In the meantime please do not

hesitate to contact the Funds legal counsel Louis T Mazawey Mark C Nielsen orAnubhav Gogna should you have any qu estions or require any additional informa tionMr Mazawey may be reached at 2028616608 or by email at ltm groom com MrNielsen may be reached at 2028615429 or by email at mcngroomcom and MrGogna may be reached at 2028612602 or by email at agognagroomcom

James D GoldenChairman SEIU Local 300 Civil ServiceForum Welfare Fund

SEIU L300000005

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 616

T|rvice20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Request20Dec209202010htm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Thursday December 09 2010 229 PM

o Sheer Jennifer (HHSOCIIO)

ubject FW SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver

Request (01947006)

ttachments SEIU Local 300 Fund Waiver Spreadsheetxls

oe Records

301) 492-4257

rom Gogna Anubhav ( AGognagroomcom) [mailtoAGognagroomcom] ent Thursday December 09 2010 951 AMo Records Joseph (HHSOCIIO)c Mazawey Lou (ltmgroomcom) Nielsen Mark (mcngroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request (01947006)

ear Mr Records

hank you for your email regarding the annual limit waiver request that was filed by the SEIU Local 300 Civil Service Forummployees Welfare Fund (the Fund) As requested we are attaching the spreadsheet that your office provided detailing

formation applicable to the Funds prescription drug benefits for which the Fund has requested a waiver of the annual limit th

urrently in effect

n response to your specific questions please note

As detailed in the Funds attestation that accompanied its waiver request the Fund was in existence prior to March 23 20

The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147140 and

The Fund is not established pursuant to the Taft-Hartley Act which applies only to benefit plans that are jointly maintained

nions and employers and which are governed by a joint board of trustees comprising an equal number of employer and union

ustees Rather the Fund was established and is maintained by the SEIU Local 300 Civil Service Forum (the Union) to provupplemental benefits -- such as prescription drug coverage -- to collectively bargained employees of New York City who are

epresented by the Union The supplemental benefits provided by the Fund (prescription drug dental vision hearing aid and

eath) are not covered by the City of New Yorks plan for such employees Accordingly the Union established the Fund to fill

his gap in coverage and to ensure that collectively bargained employees receive coverage for these important health benefits

he Fund provides these benefits with contributions from the City negotiated between the Union and the City

hope this information is helpful If you have any questions or need anything else please contact Mark Nielsen or me Mark c

e reached at 2028615429 and I can be reached at 2028612602

est regards

nubhav Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Records Joseph (HHSOCIIO) [mailtoJosephRecordshhsgov] ent Wednesday December 08 2010 514 PMo Gogna Anubhav ( AGognagroomcom)c Sheer Jennifer (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request

SEIU L300000006

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 416

contributions to the Fund are limited by contract and must cover all benefits provided bythe Fund The current CBA w ith the City will expire in March 2011

The Funds consultant has calculated the impact that raising the Funds annuallimits to $750000 wou ld have on the Fund Currently New York City contributes$ per member annually to the Fund which is used to fund all of the benefits offeredby t nd including prescription drug coverage The Fund currently pays a maximumo annua lly per covered person for prescription drugs Even w ith a limit as low as$ per year the Fund spends more than one-third of New York Citys annualcontributions on prescription drug costs alone The Fund cann ot remain solvent if it werer to raise its annual limits on prescription drug benefits from $ to $750000 -

a percent increase Indeed given that the Funds resources are severely limited -

an d because contributions rates are contractually established through a CBA that wasnegotiated long before the ACA s enactment - a percent increase in annual limitswill force the Fund to discontinue or drastically diminish offering various benefitsincluding prescription drug coverage

Further the Funds consultant estimates that implementing the $750000 annuallimit between January 1 2011 and December 31 2011 would n a conservative increase the Fun ds prescription drug costs by ap proximately percent (over $ )and result in financial insolvency absent additional funding of which there is none

According to the Funds consultant it is expected that removal of the Funds annualprescription drug maximum will cause prescription drug costs to eventually reach to times ($ to $ over the current levels This woul uire the Unionto obtain an incre e in New York Citys contribution rate of almost percent(approximately $ per covered employee per year) simply to cover the Funds additionalbenefit expenditures fo r prescription drugs during the 2011 Plan Year A contributionrate increase is not possible how ever given that New York Citys contribution rate is

contractually established in a CBA Accordingly there is no way for the Fund to obtain acontribution rate that wo uld sustain benefits offered with a $750000 an nual limit and toprevent insolvency the Funds Trustees would be forced to either cut the Fundsprescription drug benefits or to reduce other critical benefits that the Fund offers such asdental an d vision to offset the additional costs that will result from a $750000 annuallimit during the 2011 plan year Un der either scenario Fund mem bers would experiencea significant decrease in access to benefits fo r those currently covered by the [Fund]

which is what O CIIOs guidance requires fo r issuance of a waiver Se e September 32010 guidance sectIII(4)-(5)

Based on the above information we respectfully request a waiver of the $750000

restricted ann ual limit for the Plan Year commenc ing January 1 2011

5 Attestation

By m y signature below I certify that th e coverage provided by the Fund was inforce prior to September 23 2010 and that application o f the restricted a nnual limits tothe Fund for the January 1 2011 -December 31 2011 Plan Year would result in the

SEIU L300000004

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 516

Fun ds insolvency and thus a significant decrease in access to if not the total eliminationof benefits for those currently covered by the Fund

W e very much appreciate the Departments consideration of this waiverapplication and we look forward to hearing from you In the meantime please do not

hesitate to contact the Funds legal counsel Louis T Mazawey Mark C Nielsen orAnubhav Gogna should you have any qu estions or require any additional informa tionMr Mazawey may be reached at 2028616608 or by email at ltm groom com MrNielsen may be reached at 2028615429 or by email at mcngroomcom and MrGogna may be reached at 2028612602 or by email at agognagroomcom

James D GoldenChairman SEIU Local 300 Civil ServiceForum Welfare Fund

SEIU L300000005

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 616

T|rvice20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Request20Dec209202010htm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Thursday December 09 2010 229 PM

o Sheer Jennifer (HHSOCIIO)

ubject FW SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver

Request (01947006)

ttachments SEIU Local 300 Fund Waiver Spreadsheetxls

oe Records

301) 492-4257

rom Gogna Anubhav ( AGognagroomcom) [mailtoAGognagroomcom] ent Thursday December 09 2010 951 AMo Records Joseph (HHSOCIIO)c Mazawey Lou (ltmgroomcom) Nielsen Mark (mcngroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request (01947006)

ear Mr Records

hank you for your email regarding the annual limit waiver request that was filed by the SEIU Local 300 Civil Service Forummployees Welfare Fund (the Fund) As requested we are attaching the spreadsheet that your office provided detailing

formation applicable to the Funds prescription drug benefits for which the Fund has requested a waiver of the annual limit th

urrently in effect

n response to your specific questions please note

As detailed in the Funds attestation that accompanied its waiver request the Fund was in existence prior to March 23 20

The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147140 and

The Fund is not established pursuant to the Taft-Hartley Act which applies only to benefit plans that are jointly maintained

nions and employers and which are governed by a joint board of trustees comprising an equal number of employer and union

ustees Rather the Fund was established and is maintained by the SEIU Local 300 Civil Service Forum (the Union) to provupplemental benefits -- such as prescription drug coverage -- to collectively bargained employees of New York City who are

epresented by the Union The supplemental benefits provided by the Fund (prescription drug dental vision hearing aid and

eath) are not covered by the City of New Yorks plan for such employees Accordingly the Union established the Fund to fill

his gap in coverage and to ensure that collectively bargained employees receive coverage for these important health benefits

he Fund provides these benefits with contributions from the City negotiated between the Union and the City

hope this information is helpful If you have any questions or need anything else please contact Mark Nielsen or me Mark c

e reached at 2028615429 and I can be reached at 2028612602

est regards

nubhav Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Records Joseph (HHSOCIIO) [mailtoJosephRecordshhsgov] ent Wednesday December 08 2010 514 PMo Gogna Anubhav ( AGognagroomcom)c Sheer Jennifer (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request

SEIU L300000006

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 516

Fun ds insolvency and thus a significant decrease in access to if not the total eliminationof benefits for those currently covered by the Fund

W e very much appreciate the Departments consideration of this waiverapplication and we look forward to hearing from you In the meantime please do not

hesitate to contact the Funds legal counsel Louis T Mazawey Mark C Nielsen orAnubhav Gogna should you have any qu estions or require any additional informa tionMr Mazawey may be reached at 2028616608 or by email at ltm groom com MrNielsen may be reached at 2028615429 or by email at mcngroomcom and MrGogna may be reached at 2028612602 or by email at agognagroomcom

James D GoldenChairman SEIU Local 300 Civil ServiceForum Welfare Fund

SEIU L300000005

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 616

T|rvice20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Request20Dec209202010htm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Thursday December 09 2010 229 PM

o Sheer Jennifer (HHSOCIIO)

ubject FW SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver

Request (01947006)

ttachments SEIU Local 300 Fund Waiver Spreadsheetxls

oe Records

301) 492-4257

rom Gogna Anubhav ( AGognagroomcom) [mailtoAGognagroomcom] ent Thursday December 09 2010 951 AMo Records Joseph (HHSOCIIO)c Mazawey Lou (ltmgroomcom) Nielsen Mark (mcngroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request (01947006)

ear Mr Records

hank you for your email regarding the annual limit waiver request that was filed by the SEIU Local 300 Civil Service Forummployees Welfare Fund (the Fund) As requested we are attaching the spreadsheet that your office provided detailing

formation applicable to the Funds prescription drug benefits for which the Fund has requested a waiver of the annual limit th

urrently in effect

n response to your specific questions please note

As detailed in the Funds attestation that accompanied its waiver request the Fund was in existence prior to March 23 20

The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147140 and

The Fund is not established pursuant to the Taft-Hartley Act which applies only to benefit plans that are jointly maintained

nions and employers and which are governed by a joint board of trustees comprising an equal number of employer and union

ustees Rather the Fund was established and is maintained by the SEIU Local 300 Civil Service Forum (the Union) to provupplemental benefits -- such as prescription drug coverage -- to collectively bargained employees of New York City who are

epresented by the Union The supplemental benefits provided by the Fund (prescription drug dental vision hearing aid and

eath) are not covered by the City of New Yorks plan for such employees Accordingly the Union established the Fund to fill

his gap in coverage and to ensure that collectively bargained employees receive coverage for these important health benefits

he Fund provides these benefits with contributions from the City negotiated between the Union and the City

hope this information is helpful If you have any questions or need anything else please contact Mark Nielsen or me Mark c

e reached at 2028615429 and I can be reached at 2028612602

est regards

nubhav Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Records Joseph (HHSOCIIO) [mailtoJosephRecordshhsgov] ent Wednesday December 08 2010 514 PMo Gogna Anubhav ( AGognagroomcom)c Sheer Jennifer (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request

SEIU L300000006

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 616

T|rvice20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Request20Dec209202010htm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Thursday December 09 2010 229 PM

o Sheer Jennifer (HHSOCIIO)

ubject FW SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver

Request (01947006)

ttachments SEIU Local 300 Fund Waiver Spreadsheetxls

oe Records

301) 492-4257

rom Gogna Anubhav ( AGognagroomcom) [mailtoAGognagroomcom] ent Thursday December 09 2010 951 AMo Records Joseph (HHSOCIIO)c Mazawey Lou (ltmgroomcom) Nielsen Mark (mcngroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request (01947006)

ear Mr Records

hank you for your email regarding the annual limit waiver request that was filed by the SEIU Local 300 Civil Service Forummployees Welfare Fund (the Fund) As requested we are attaching the spreadsheet that your office provided detailing

formation applicable to the Funds prescription drug benefits for which the Fund has requested a waiver of the annual limit th

urrently in effect

n response to your specific questions please note

As detailed in the Funds attestation that accompanied its waiver request the Fund was in existence prior to March 23 20

The Fund is in compliance with the grandfathering provisions pursuant to 45 CFR 147140 and

The Fund is not established pursuant to the Taft-Hartley Act which applies only to benefit plans that are jointly maintained

nions and employers and which are governed by a joint board of trustees comprising an equal number of employer and union

ustees Rather the Fund was established and is maintained by the SEIU Local 300 Civil Service Forum (the Union) to provupplemental benefits -- such as prescription drug coverage -- to collectively bargained employees of New York City who are

epresented by the Union The supplemental benefits provided by the Fund (prescription drug dental vision hearing aid and

eath) are not covered by the City of New Yorks plan for such employees Accordingly the Union established the Fund to fill

his gap in coverage and to ensure that collectively bargained employees receive coverage for these important health benefits

he Fund provides these benefits with contributions from the City negotiated between the Union and the City

hope this information is helpful If you have any questions or need anything else please contact Mark Nielsen or me Mark c

e reached at 2028615429 and I can be reached at 2028612602

est regards

nubhav Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Records Joseph (HHSOCIIO) [mailtoJosephRecordshhsgov] ent Wednesday December 08 2010 514 PMo Gogna Anubhav ( AGognagroomcom)c Sheer Jennifer (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Request

SEIU L300000006

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 716

T|rvice20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Request20Dec209202010htm[08122011 440

Dear Mr Gogna

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

I Please complete the entire annual limits spreadsheet attached Please return the completed spreadsheet to temail address as an attachment We will only be able to process spreadsheets that are fully complete (ievery cell should contain the information requested) If a cell on the spreadsheet does not pertain to you

plan please write ldquoNonerdquo andor 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

middot 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 147140

middot Confirm whether the plan was created pursuant to the Taft-Hartley Act

n order to complete your application please provide this information by 500 pm December 9 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

oseph P Records

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

ffice of Consumer Support

501 Wisconsin Avenue NW

ethesda Maryland 20814

301) 492-4257

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 dissemin

distributed or copied to persons not authorized to receive the information Unauthhorized disclosure may result in prosecution to the full extent of the l

otice This message is intended only for use by the person or entity to which it is addressed Because it may contain confiden

formation intended solely for the addressee you are notified that any disclosing copying downloading distributing or retainin

his message and any attached files is prohibited and may be a violation of state or federal law If you received this message

rror please notify the sender by reply mail and delete the message and all attached files

o comply with US Treasury Regulations we also inform you that unless expressly stated otherwise any tax advice containe

his communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Reven

ode and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres

this communication

SEIU L300000007

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 816

T|2030020Civil20Service20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Requesthtm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Wednesday December 08 2010 514 PM

o AGognagroomcom

c Sheer Jennifer (HHSOCIIO)

ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Reques

ttachments Waiver Application Formxls

Dear Mr Gogna

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

I Please complete the entire annual limits spreadsheet attached Please return the completed spreadsheet this email address as an attachment We will only be able to process spreadsheets that are fully complet(ie every cell should contain the information requested) If a cell on the spreadsheet does not pertain tyour plan please write ldquoNonerdquo andor provide an explanation regarding why you are unable to completethat particular cell in a separate document

II

In addition please provide the following information

middot 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 147140

middot Confirm whether the plan was created pursuant to the Taft-Hartley Act

n order to complete your application please provide this information by 500 pm December 9 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

oseph P Records

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

ffice of Consumer Support

501 Wisconsin Avenue NW

ethesda Maryland 20814

301) 492-4257

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 dissemin

distributed or copied to persons not authorized to receive the information Unauthhorized disclosure may result in prosecution to the full extent of the l

SEIU L300000008

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 916

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Appl ican t

(Plan Policy

Situs) City

App licant

(Plan

Policy

Situs)

State

Plan Policy

Effective Date

(mmddyyyy)

Contact

Name

Street

Addr ess City State Zip Code

Phone

Number

(including

area code)

Email

Address

Type

Cover

(eg L

Benefit

Rx only

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1 New York NY

112011

Plan Year

Mark C

Nielsen

Anubhav

Gogna

1701

Pennsylvania

Avenue

NW Washington DC 20006

202-861-

5429 202-

861-2602 mcngroom Limited

PRA 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 validinformation collection is 0938-1105 The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response including thesearch existing data resources gather the data needed and complete and review the information collection If you have comments concerning the accuracy of the time estim

- - -

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1016

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application) Hospitalization Laboratory Pediatric

Maternity

Newborn

Mental Health

Substance

Abuse

Rehabilitative

Devices

Preventive

Wellness Prescription

Current Essential Benefits Annual Lim its (Annual Limi t for Each Essential Benefit)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

None None None None None None None

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1116

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Individual Employee

Tier

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Empl

contrib

(if appl

Projected Rate Increa

from compliance wit

Limit Restriction (in

Premium by

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver

Granted (in dollars)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

Employee +Family

When completing the columns requesting premium rate information please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee Employee +Spouse Employee +

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1216

T|OWApplications20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20122110htm[08122011 440

rom Botwinick Alexandra (HHSOCIIO)ent Tuesday December 21 2010 208 PM

To mcngroomcom agognagroomcomCc Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annimits Requirements 12-21-2010

mportance High

Attachments Updated Jan 1 Approval Letter pdf

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000012

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 816

T|2030020Civil20Service20Forum20Employees20Welfare20Fund20Annual20Limits20Waiver20Requesthtm[08122011 440

rom Records Joseph (HHSOCIIO)

ent Wednesday December 08 2010 514 PM

o AGognagroomcom

c Sheer Jennifer (HHSOCIIO)

ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Annual Limits Waiver Reques

ttachments Waiver Application Formxls

Dear Mr Gogna

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

I Please complete the entire annual limits spreadsheet attached Please return the completed spreadsheet this email address as an attachment We will only be able to process spreadsheets that are fully complet(ie every cell should contain the information requested) If a cell on the spreadsheet does not pertain tyour plan please write ldquoNonerdquo andor provide an explanation regarding why you are unable to completethat particular cell in a separate document

II

In addition please provide the following information

middot 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 147140

middot Confirm whether the plan was created pursuant to the Taft-Hartley Act

n order to complete your application please provide this information by 500 pm December 9 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

oseph P Records

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

ffice of Consumer Support

501 Wisconsin Avenue NW

ethesda Maryland 20814

301) 492-4257

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 dissemin

distributed or copied to persons not authorized to receive the information Unauthhorized disclosure may result in prosecution to the full extent of the l

SEIU L300000008

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 916

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Appl ican t

(Plan Policy

Situs) City

App licant

(Plan

Policy

Situs)

State

Plan Policy

Effective Date

(mmddyyyy)

Contact

Name

Street

Addr ess City State Zip Code

Phone

Number

(including

area code)

Email

Address

Type

Cover

(eg L

Benefit

Rx only

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1 New York NY

112011

Plan Year

Mark C

Nielsen

Anubhav

Gogna

1701

Pennsylvania

Avenue

NW Washington DC 20006

202-861-

5429 202-

861-2602 mcngroom Limited

PRA 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 validinformation collection is 0938-1105 The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response including thesearch existing data resources gather the data needed and complete and review the information collection If you have comments concerning the accuracy of the time estim

- - -

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1016

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application) Hospitalization Laboratory Pediatric

Maternity

Newborn

Mental Health

Substance

Abuse

Rehabilitative

Devices

Preventive

Wellness Prescription

Current Essential Benefits Annual Lim its (Annual Limi t for Each Essential Benefit)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

None None None None None None None

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1116

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Individual Employee

Tier

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Empl

contrib

(if appl

Projected Rate Increa

from compliance wit

Limit Restriction (in

Premium by

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver

Granted (in dollars)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

Employee +Family

When completing the columns requesting premium rate information please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee Employee +Spouse Employee +

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1216

T|OWApplications20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20122110htm[08122011 440

rom Botwinick Alexandra (HHSOCIIO)ent Tuesday December 21 2010 208 PM

To mcngroomcom agognagroomcomCc Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annimits Requirements 12-21-2010

mportance High

Attachments Updated Jan 1 Approval Letter pdf

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000012

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 916

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Appl ican t

(Plan Policy

Situs) City

App licant

(Plan

Policy

Situs)

State

Plan Policy

Effective Date

(mmddyyyy)

Contact

Name

Street

Addr ess City State Zip Code

Phone

Number

(including

area code)

Email

Address

Type

Cover

(eg L

Benefit

Rx only

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1 New York NY

112011

Plan Year

Mark C

Nielsen

Anubhav

Gogna

1701

Pennsylvania

Avenue

NW Washington DC 20006

202-861-

5429 202-

861-2602 mcngroom Limited

PRA 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 validinformation collection is 0938-1105 The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response including thesearch existing data resources gather the data needed and complete and review the information collection If you have comments concerning the accuracy of the time estim

- - -

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1016

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application) Hospitalization Laboratory Pediatric

Maternity

Newborn

Mental Health

Substance

Abuse

Rehabilitative

Devices

Preventive

Wellness Prescription

Current Essential Benefits Annual Lim its (Annual Limi t for Each Essential Benefit)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

None None None None None None None

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1116

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Individual Employee

Tier

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Empl

contrib

(if appl

Projected Rate Increa

from compliance wit

Limit Restriction (in

Premium by

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver

Granted (in dollars)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

Employee +Family

When completing the columns requesting premium rate information please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee Employee +Spouse Employee +

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1216

T|OWApplications20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20122110htm[08122011 440

rom Botwinick Alexandra (HHSOCIIO)ent Tuesday December 21 2010 208 PM

To mcngroomcom agognagroomcomCc Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annimits Requirements 12-21-2010

mportance High

Attachments Updated Jan 1 Approval Letter pdf

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000012

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1016

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application) Hospitalization Laboratory Pediatric

Maternity

Newborn

Mental Health

Substance

Abuse

Rehabilitative

Devices

Preventive

Wellness Prescription

Current Essential Benefits Annual Lim its (Annual Limi t for Each Essential Benefit)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

None None None None None None None

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1116

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Individual Employee

Tier

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Empl

contrib

(if appl

Projected Rate Increa

from compliance wit

Limit Restriction (in

Premium by

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver

Granted (in dollars)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

Employee +Family

When completing the columns requesting premium rate information please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee Employee +Spouse Employee +

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1216

T|OWApplications20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20122110htm[08122011 440

rom Botwinick Alexandra (HHSOCIIO)ent Tuesday December 21 2010 208 PM

To mcngroomcom agognagroomcomCc Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annimits Requirements 12-21-2010

mportance High

Attachments Updated Jan 1 Approval Letter pdf

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000012

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1116

ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Individual Employee

Tier

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Empl

contrib

(if appl

Projected Rate Increa

from compliance wit

Limit Restriction (in

Premium by

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver

Granted (in dollars)

SEIU Local

300 Civil

Service

Forum

Employees

Welfare

Fund Plan 1

PRA Disclosure Statement

According to the Paperworkinformation collection is 093search existing data resourc

Employee +Family

When completing the columns requesting premium rate information please express the premium rates as a compremiums are a range based on years of service or age) and by tier (Employee Employee +Spouse Employee +

Document obtained by CompleteColorado

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1216

T|OWApplications20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20122110htm[08122011 440

rom Botwinick Alexandra (HHSOCIIO)ent Tuesday December 21 2010 208 PM

To mcngroomcom agognagroomcomCc Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annimits Requirements 12-21-2010

mportance High

Attachments Updated Jan 1 Approval Letter pdf

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000012

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1216

T|OWApplications20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20122110htm[08122011 440

rom Botwinick Alexandra (HHSOCIIO)ent Tuesday December 21 2010 208 PM

To mcngroomcom agognagroomcomCc Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annimits Requirements 12-21-2010

mportance High

Attachments Updated Jan 1 Approval Letter pdf

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000012

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1316

SEIU L300000013

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1416

SEIU L300000014

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1516

T|cations20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20receipt20122110htm[08122011 440

rom Gogna Anubhav (AGognagroomcom) [AGognagroomcom]ent Tuesday December 21 2010 217 PM

To Botwinick Alexandra (HHSOCIIO) Nielsen Mark (mcngroomcom)Cc Habit Sandra (HHSOCIIO) Mazawey Lou (ltmgroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the

Annual Limits Requirements 12-21-2010

Ms Botwinick

his is to confirm receipt of your email with respect to the approval of the application for a Waiver of the Annual Limitsequirements for the SEIU Local 300 Civil Service Forum Employees Welfare Fund Thank you

est regards

nu Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Botwinick Alexandra (HHSOCIIO) [mailtoAlexandraBotwinickhhsgov]ent Tuesday December 21 2010 208 PMo Nielsen Mark (mcngroomcom) Gogna Anubhav (AGognagroomcom)c Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annual Limitsequirements 12-21-2010mportance High

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000015

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1416

SEIU L300000014

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1516

T|cations20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20receipt20122110htm[08122011 440

rom Gogna Anubhav (AGognagroomcom) [AGognagroomcom]ent Tuesday December 21 2010 217 PM

To Botwinick Alexandra (HHSOCIIO) Nielsen Mark (mcngroomcom)Cc Habit Sandra (HHSOCIIO) Mazawey Lou (ltmgroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the

Annual Limits Requirements 12-21-2010

Ms Botwinick

his is to confirm receipt of your email with respect to the approval of the application for a Waiver of the Annual Limitsequirements for the SEIU Local 300 Civil Service Forum Employees Welfare Fund Thank you

est regards

nu Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Botwinick Alexandra (HHSOCIIO) [mailtoAlexandraBotwinickhhsgov]ent Tuesday December 21 2010 208 PMo Nielsen Mark (mcngroomcom) Gogna Anubhav (AGognagroomcom)c Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annual Limitsequirements 12-21-2010mportance High

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000015

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1516

T|cations20with20NO201260020Response20[YELLOW]SEIU20Local20300Approval20receipt20122110htm[08122011 440

rom Gogna Anubhav (AGognagroomcom) [AGognagroomcom]ent Tuesday December 21 2010 217 PM

To Botwinick Alexandra (HHSOCIIO) Nielsen Mark (mcngroomcom)Cc Habit Sandra (HHSOCIIO) Mazawey Lou (ltmgroomcom)ubject RE SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the

Annual Limits Requirements 12-21-2010

Ms Botwinick

his is to confirm receipt of your email with respect to the approval of the application for a Waiver of the Annual Limitsequirements for the SEIU Local 300 Civil Service Forum Employees Welfare Fund Thank you

est regards

nu Gogna

Anubhav Gogna 1701 Pennsylvania Ave NW Washington DC 20006 Phone 202-861-2602 Fax 202-659-4503

wwwGroomcom AGognagroomcom

rom Botwinick Alexandra (HHSOCIIO) [mailtoAlexandraBotwinickhhsgov]ent Tuesday December 21 2010 208 PMo Nielsen Mark (mcngroomcom) Gogna Anubhav (AGognagroomcom)c Habit Sandra (HHSOCIIO)ubject SEIU Local 300 Civil Service Forum Employees Welfare Fund Approval Letter for a Waiver of the Annual Limitsequirements 12-21-2010mportance High

ood Afternoon

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

ection 2711 for SEIU Local 300 Civil Service Forum Employees Welfare Fund HHS has reviewed your

pplication and made its determination Please see the attached letter

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

lease let me know if I can be of further assistance

incerely

Alexandra Botwinick

ffice of Oversight

HHSOCIIOexandrabotwinickhhsgov

SEIU L300000015

Document obtained by CompleteColoradocom

7272019 SEIU Local 300 - Redacted Bates HWM

httpslidepdfcomreaderfullseiu-local-300-redacted-bates-hwm 1616

otice This message is intended only for use by the person or entity to which it is addressed Because it may contain confiden

formation intended solely for the addressee you are notified that any disclosing copying downloading distributing or retainin

his message and any attached files is prohibited and may be a violation of state or federal law If you received this message

rror please notify the sender by reply mail and delete the message and all attached files

o comply with US Treasury Regulations we also inform you that unless expressly stated otherwise any tax advice containe

his communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Reven

ode and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres

this communication

Document obtained by CompleteColoradocom