Sunview Vineyards - Redacted HWM

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Pages 4 through 81 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4

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///co-adshare/...cessing%20Team/Mike/Sunview%20Vineyards%20of%20California,%20Inc/Request%20for%20info%2012.22.10.htm[11/08/2011 3:44

rom: Campbell, Lisa (HHS/OCIIO)ent: Wednesday, December 22, 2010 9:12 AM

To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Waiver application for Sunview Vineyards of California, Inc.

Attachments: Waiver Application Form.xlsxDear 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:

I. Please complete the entire annual limits spreadsheet, attached to the email and available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed 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.

II. In addition, please provide the following information:

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

grandfathering provisions, pursuant to 45 CFR 147.140?

Pursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of Septembe

23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans thpreviously had a lifetime limit may add an annual limit not less than the lifetime limit without affecting thegrandfather status of the plan. Please confirm that any lifetime limit will be eliminated from your plan. If yplan does not have any lifetime limit, please note.

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

Once this information is received and the application is complete, it will be processed by the Department of HealthHuman Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decisionwithin 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waecision.

lease contact me if you have any questions relating to this application. Thank you.

sa M. Campbell

ivision of Market Compliance

ffice of OversightHS/OCIIO

301) 492-4140

[email protected]

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

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the

extent of the law.

SUNVIEW:000005


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///co-adshare/...ssing%20Team/Mike/Sunview%20Vineyards%20of%20California,%20Inc/Completed%20spreadsheet%2012.23.10.htm[11/08/2011 3:44

rom: Campbell, Lisa (HHS/OCIIO)ent: Thursday, December 23, 2010 2:43 PM

To: Curtis, Barbara (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)ubject: Completed Reviewer application for Sunview Vineyards of California

Attachments: Annual Limit Waiver Reviewer Spreadsheet (Sunview Vineyards).xlsi Barbara,

lease let me know if you have any questions. Thanks!

sa

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Appl icant ID

Number

Annual L imit

Waiver

Request

Appl icant

Name

Policy Name

(use a new

row for each

policy

application)

Appl icant

(Plan/ Policy

Situs) City

Appl icant

(Plan/

Policy

Situs) State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Address

100901-0001

Applicant

ABC Plan 1 Washington DC 01/01/2011 J ane Doe

100 ABC

Drive

100901-0001

Applicant

ABC Plan 1 Washington DC 01/01/2011 J ane Doe

100 ABC

Drive

101201126 Sunview MedicalBenefit Plan of

Delano CA 01/01/2011 DanGallegos 1998Road

California,

Inc.

Sunview

Vineyards of

California, Inc.


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Phone

Number

(including

area code)

(xxx-xxx-

xxx)

Email

Address

Type of

Coverage (e.g.,

Limited

Benefit, HRA,

Rx only, Other)

Self-

Insured

Individual or

Group Policy

Total Number

of

Individuals

Covered by

Policy

(include all

dependents

covered)

Current Plan

Annual L imit

(in dollars) Ambulatory

1-800-ABC-

1234

abc@abcheal

thplan.com Limited Benefit Yes Group 4,000 $100,000 None1-800-ABC-

1234

abc@abcheal

thplan.com Limited Benefit Yes Group 2,500 $100,000 None

1661393 dangallegos@sunviewvin

LimitedBenefit Yes Group or1661201

2988(cell)

eyards.com


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Hospitalization Laboratory Pediatric

Maternity/

Newborn

Mental Health/

Substance

Abuse

Rehabilitative/

Devices

Prev

Wel

None None None None None None

None None None None None None

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


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Plan

Deductible

Copay (if

applicable

)

Coinsuranc

e (if

applicable)

Copay (if

applicable

)

Coinsura

nce (if

applicable

)

Copay (if

applicable

)

Coinsura

nce (if

applicable

)

Copay (if

applicable

)

Coinsurance

(if applicable)

Ind

Em

Tie

$500.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00 None

$1,000.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00 None

Rx Copay/Coninsurance

Office Visit

Copays/Coinsurance

Hospital Inpatient

Copay/Coinsurance

Emergency Room

Copay/Coinsurance


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Employer

cont ribut ion Total

Employee

contribution

Employer

contribution Total

Employee

contribution

Employer

contribution

$600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800.0

$1,100.00 $1,205.00 $115.00 $1,150.00 $1,265.00 $150.00 $1,400.

y Premium Rates or Premium

s (in dol lars)*:

Renewal Monthly Premium Rates or Premium

Equivalent Rates if Waiver Granted (in

dollars)*

Projected Rate Increase that wou

with $750,000 Annual Limit Restr

Premium by Individual)*


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Projected Rate Increase

that would result from

compliance with $750,000

Annual L imit Restrict ion (in

dollars)(Average Premium

by Individual) (Difference

of Column AU and AR

divided by Column AR)

Decrease in

Access to

Benefits thatwould result

from

compliance

with $750,000

Annual L imit

Restriction

(describe

briefly)

Plan

Administ r

ator/ CEO

of Health

Insurance

Issuer

Name

Title of

Individual

Providing

At tes tat ion

Taft-Hartley

Plan

If Yes Taft-

Hartley then

Date

Complianc

with

Grandfathe

Regulation

21.71% None J ane Doe

Plan

Administrator Yes 01/01/2013 Yes

22.53% None J ane Doe

Plan

Administrator Yes 01/01/2013 Yes

AndrewZaninovich

Plan No N/A Yes


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Factor 1 for Decision Factor 2 for Decision

3: The change in premium in percentage terms.

3: The change in premium in percentage terms.

1:Asignificantdecreaseinaccesstobenefits. 3:Thechangeinpremiuminpercentageterms.

OCIIO Reviewer


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Factor 3 for Decision Factor 4 for Decision

OCIIO S

Recomm

ation for

Approva

Disappro

Appro

Appro

4:Thechangeinpremiuminabsolutedollarterms. 6:Thenumberofenrolleesundertheplanseeking Approve

.


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Comments

Final

Decision

Decision

Date

Date of

Waiver

Approval/

Disappro

val Letter

Sent Y/N

Date of

Letter

Confirmat

ion of

Receipt

of

Approval

Acces

File

Waiver Application indicates that the

Partici atin Em lo ers cannot

Final Decision and Coorespondence

afford to absorb the increase in

costs that would result from

increasing the existing annual limit

of $ to $750,000. Theapplication states that the

employees, the majority of which

are seasonal and migrant farm

workers, could not afford such

increase. As a result, it is likely thatthere would be a decrease in

access if the annual limit must be

raised to $750,000.


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Waiver application for Sunview Vineyards of California, Inc.

///co-adshare/...Torres/DFOI%20Processing%20Team/Mike/Sunview%20Vineyards%20of%20California,%20Inc/File%2012.28.10.htm[11/08/2011 3:45

rom: Campbell, Lisa (HHS/OCIIO)ent: Tuesday, December 28, 2010 11:08 AM

To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver application for Sunview Vineyards of California, Inc.

Attachments: Fed Ex Confirmation to HHS.pdfYI-for the file

rom: Dan Gallegos [mailto:[email protected]]ent: Tuesday, December 28, 2010 10:41 AMo: Campbell, Lisa (HHS/OCIIO)ubject: Re: Waiver application for Sunview Vineyards of California, Inc.

Hi Ms. Campbell.I am following up on our waiver application and hope that it has been processed. As you may know, ourapplication was received by HHS on December 1, 2010 as can be seen in the attached deliveryconfirmation. In that HHS has committed to process applications within 30 days, I expected that ourapplication would be processed at the latest by December 30, 2010. As stated in our application, the Planyear ends on December 31 and based on the expected increase in costs to the Plan if it is required to meet

the annual limits as required by PPACA, the Participating Employers and participants (the majority ofwhich are farm workers) could not afford the increase in costs and the Participating Employers may haveno other choice but to terminate the Plan. Therefore, it is imperative that a determination of our applicationbe made by December 30, 2010.

Thank you for your cooperation and efforts in reviewing our application and hope to hear from you soon.Dan Gallegos

n 12/23/10 11:40 AM, "Campbell, Lisa (HHS/OCIIO)" wrote:

Dear Mr. Gallegos:

hank you for your information. Your application is now complete and you receive a determination of your applicawithin 30 days. We recognize your need to have a more immediate response and we will make every effort to prochis application as soon as possible. I will contact you early next week to provide an update.

hank you.

Happy Holidays!isa

sa M. Campbellivision of Market Complianceffice of OversightHS/OCIIO

301) [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, distribu

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

SUNVIEW:000016


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rom: Dan Gallegos [mailto:[email protected]]ent: Wednesday, December 22, 2010 7:40 PMo: Campbell, Lisa (HHS/OCIIO)ubject: RE: Waiver application for Sunview Vineyards of California, Inc.

Dear Ms. Campbell:

lease find below and attached our response to your email for additional information to support our application fWaiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Attached is

ompleted spreadsheet as per Section I of your email. Below are responses to the questions in Section II of youmail.

he Plan was in existence prior to March 23, 2010. The Plan was originally established in 1984. The current Plaerms have been in effect since January 1, 2006. No changes have been made to the Plan since March 23, 20hat would cause it to lose its grandfathered status under the Patient Protection and Affordable Care ActPPACA"). The Plan is being amended effective January 1, 2011 to comply with the requirements of PPACA thpply to grandfathered health plans with the exception of the elimination of the annual limits pending the outcomhis Waiver Application.

The Plan has never had a lifetime limit. Part 2 Section 18 of the Plan provides for an overall annual limit ofs follows:

Medical Limitation. The amount of the medical limitation (hereinafter referred to as Limitation) applica

o a Participant shall be ). Notwithstanding the preceding sentence

he event of a Disaster, the Participant shall be eligible for no more than )

enefits under the Plan arising out of or relating to such Disaster. The Li djustment as follows:

a) There shall be subtracted from a Participants Limitation an amount equal to the total amount of any

enefits paid to such Participant under the provisions of this Plan during each calendar year.

b) After each calendar year there shall be added to a Participants Limitation a sum equal to the lesser

1) ); or (2) the total amount of all benefits payable to such Particip

nder the Plan for covered expenses incurred during such calendar year; provided, however, that themaximum amount of the Limitation shall at no time exceed ).

c) If, for any Participant, ) of benefits are paid with respect to any

ne Disability or disease, then, regardless of whether such benefits are paid over one or more calendar

ears, the Participant shall be eligible for no more than ) per calendar y

f benefits under the Plan with respect to such Disability or disease.

d) If, for any Participant, of benefits are paid with respect to any one

Disaster, then, regardless of whether such benefits are paid over one or more calendar years, the

articipant shall be eligible for no further benefits under the Plan with respect to such Disaster.

he Plan was not created pursuant to the Taft-Hartley Act.

he following comments correspond to information requested on the spreadsheet (attached to this email):

he calculation in column AU of the spreadsheet (Projected Rate Increase that would result from compliance wit750,000 Annual Limit Restriction) does not appear to be correct. The projected rate would increase from $er employee per month to $ per employee per month, which accounts for a % increase, not %alculated in your worksheet. In either event, the Participating Employers are unable to absorb the increase in co

Column AV (Decrease in Access to Benefits that would result from compliance with $750,000 Annual LimitRestriction) did not provide sufficient space to provide our full response. As indicated in our initial WaiverApplication, the Participating Employers cannot afford to absorb the estimated % increase in costs that woul

SUNVIEW:000017
mailto:[email protected]%5dmailto:[email protected]%5d


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esult from increasing the existing annual limit of $ to $750,000. Nor do we anticipate our employees, themajority of which are seasonal and migrant farm w , could afford such increase. As a result, it is likely thathere would be a % decrease in access if the annual limit must be raised to $750,000.

We would appreciate an immediate response to this matter. Our original application was sent November 23, 201nd we had hoped for a response by this date. If the waiver is not approved by December 30, 2010, the Compa

may have no other choice but to terminate the Plan. We hope to avoid any disruption in benefits to the planarticipants.

hank you for your prompt attention to this matter. Please feel free to contact me if you have any other questionincerely,

Daniel M. Gallegos, SPHRDirector of Human Resources

unview Vineyards of California, Inc. and Related Entities651 Pegasus Dr., Suite 119akersfield, CA 9330861-393-2892 x 3228 office61-201-2988 cell

rom: Campbell, Lisa (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 22, 2010 6:12 AMo: '[email protected]'c: Habit, Sandra (HHS/OCIIO)ubject: Waiver application for Sunview Vineyards of California, Inc.

Dear 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:

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

I. In addition, please provide the following information:

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

randfathering provisions, pursuant to 45 CFR 147.140?

Pursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23

010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previousad a lifetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status he plan. Please confirm that any lifetime limit will be eliminated from your plan. If your plan does not have any

SUNVIEW:000018
mailto:[email protected]%5dhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html.http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html.mailto:[email protected]%5d


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fetime limit, please note.

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

Once this information is received and the application is complete, it will be processed by the Department of Health

Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decisionwithin 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waecision.

lease contact me if you have any questions relating to this application. Thank you.

sa M. Campbellivision of Market Complianceffice of OversightHS/OCIIO

301) 492-4140

[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, distribu

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

SUNVIEW:000019


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///co-adshare/...pproval%20Letter%20for%20a%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-30-2010.htm[11/08/2011 3:45:

rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 30, 2010 4:59 PM

To: '[email protected]'ubject: Sunview Vineyards of California, Inc. Approval Letter for a Waiver of the Annual Limits Requirements 10-2010

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdfood Afternoon,

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

ection 2711 for Sunview Vineyards of California, Inc.. HHS has reviewed your application and made its

etermination. 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

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

[email protected]

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publiclysclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e

f the law.

SUNVIEW:000020
mailto:[email protected]:[email protected]


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Sunview Vineyards of California, Inc. Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010

rom: Dan Gallegos [[email protected]]ent: Friday, December 31, 2010 1:21 AM

To: Habit, Sandra (HHS/OCIIO)Cc: Campbell, Lisa (HHS/OCIIO)ubject: Re: Sunview Vineyards of California, Inc. Approval Letter for a Waiver of the Annual Limits Requiremen2-30-2010

mportance: Highear Ms. Habit,

his email is to confirm receipt of your email message and approval our of waiver application. Thank you very much for yo

fforts and all at HHS involved in approving our waiver application. We wish you a Happy New Year.

ncerely,

aniel M. Gallegos

irector of Human Resources

n 12/30/10 1:58 PM, "Habit, Sandra (HHS/OCIIO)" wrote:

Good Afternoon,

Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the

PHS Act Section 2711 for Sunview Vineyards of California, Inc.. HHS has reviewed your

application and made its determination. Please see the attached letter.

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

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

Sincerely

Sandy Habit

Department of Health and Human Services

Office of Consumer Information and Insurance Oversight

301-492-4175

[email protected]

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not

been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not

be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosures

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

Sunview Vineyards - Redacted HWM

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