seiu local 300 - redacted bates hwm
TRANSCRIPT
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
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7272019 SEIU Local 300 - Redacted Bates HWM
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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
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7272019 SEIU Local 300 - Redacted Bates HWM
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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
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7272019 SEIU Local 300 - Redacted Bates HWM
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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
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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
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7272019 SEIU Local 300 - Redacted Bates HWM
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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
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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
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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)
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
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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
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SEIU L300000013
Document obtained by CompleteColoradocom
7272019 SEIU Local 300 - Redacted Bates HWM
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SEIU L300000014
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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
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 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)
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 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 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
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 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)
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 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 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
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 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)
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 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 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
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 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)
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 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 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
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)
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 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 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
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)
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 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 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
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)
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 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 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
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)
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 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 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
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 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 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
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 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 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
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 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
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 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
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 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
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
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