ulster greene arc - combined redacted-bates hw
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Pages 3 through 14 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4
UlsterGreene:000003
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//T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2020%202010.htm[07/20/2011 3:40
rom: Sheer, Jennifer (HHS/OCIIO)
ent: Monday, December 20, 2010 2:53 PM
o: '[email protected]'
ubject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application
ttachments: Waiver Application Form.xls
ollow Up Flag: Follow up
ag Status: Completed
Dear Applicant:
hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:
I. Please complete the entire annual limits spreadsheet, attached to this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet donot pertain to your plan, please write None, and/or provide an explanation regarding why you are unabto complete that particular cell in a separate document.
II. In addition, please provide the following information:
Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance withgrandfathering provisions, pursuant to 45 CFR 147.140?
Confirm whether the plan was created pursuant to the Taft-Hartley Act. If yes:
o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008.
o Please provide the date for which the Collective Bargaining Agreement will expire.
n order to complete your application, please provide this information by 5:00 pm, December 21, 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.
--------------------------------
ennifer L. O. Sheer
ffice of Consumer Support
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
01-492-4487
UlsterGreene:000004
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//T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2021%202010.htm[07/20/2011 3:40
rom: John McHugh [[email protected]]
ent: Tuesday, December 21, 2010 4:01 PM
o: Sheer, Jennifer (HHS/OCIIO)
c: Mark Vanyo
ubject: RE: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application
ttachments: Copy of Waiver Application Form (Final)UGARC.xls
ollow Up Flag: Follow up
ag Status: Completed
ear Ms. Sheer:
n regards to our application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act).
lease find attached the completed annual limits spreadsheet. In addition, please find the information requested in Part I
nswered in red.
you have any questions or need any additional information, please do not hesitate to contact me.
hank you.
ohn
ohn McHugh
hief Financial Officer
lster-Greene ARC
71 Albany Avenue
ingston, NY 12401
hone: (845) 331-4300 Ext. 256
ax: (845) 331-4931
mail:[email protected]
Mission: " To offer people with intellectual and other developmental disabilities opportunities to live and experie
full lives".
To donate to Ulster-Greene ARC Foundation, click on the donate button below. Thank you for your supp
rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Monday, December 20, 2010 2:53 PMo: John McHughubject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application
UlsterGreene:000005
mailto:[email protected]:[mailto:[email protected]]mailto:[mailto:[email protected]]mailto:[mailto:[email protected]]https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=5713025mailto:[email protected] -
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//T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2021%202010.htm[07/20/2011 3:40
Dear Applicant:
hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:
I. Please complete the entire annual limits spreadsheet, attached to this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet donot pertain to your plan, please write None, and/or provide an explanation regarding why you are unab
to complete that particular cell in a separate document.
II. In addition, please provide the following information:
Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with
grandfathering provisions, pursuant to 45 CFR 147.140? Yes, the plan was in existence prior to March 22010. No, we are NOT grandfathering the plan for purposes of this waiver.
Confirm whether the plan was created pursuant to the Taft-Hartley Act. If yes: No, the plan was NOT
created pursuant to the Taft-Hartley Act.o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008. N/A
o Please provide the date for which the Collective Bargaining Agreement will expire. N/A
n order to complete your application, please provide this information by 5:00 pm, December 21, 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.
--------------------------------
ennifer L. O. Sheer
ffice of Consumer Support
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
01-492-4487
OTICE OF PRIVILEGE and CONFIDENTIALITY
he information contained in this electronic mail is privileged and
onfidential intended solely for the addressee. If the reader of this
message is not the intended recipient, you are hereby notified that
ny dissemination, distribution, or reproduction of this electronic
mail is strictly prohibited. If you have received this electronic mail
error, please contact Ulster-Greene ARC at 845-331-4300 ext.275
nd delete and destroy the original electronic mail and all copies.
hank you.
UlsterGreene:000006
mailto:[email protected]:[email protected] -
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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
(mm/dd/yyyy)
Contact
Name
Street
Addr ess City State Zip Code
Phone
Number
(including
area code)
Email
Address
Type
Cover
(e.g., L
Benefit,
Rx only,
Applicant
ABC Plan 1 Washington DC 01/01/2011 J ane Doe
100 ABC
Drive Washington DC 20201
1-800-ABC-
1234
abc@abchea
lthplan.com Limited
UlsterGreene ARC
StandaloneHRA Kingston NY 01/01/2011
J ohnMcHugh
471 AlbanyAve Kingston NY 12401
1-845-331-4300
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 estimimproving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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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)
Applicant
ABC Plan 1
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)
UlsterGreene ARC
StandaloneHRA
PRA Disclosure Statement
According to the Paperworkinformation collection is 093search existing data resourcimproving this form, please
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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)
Applicant
ABC Plan 1
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
Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800
Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:
Renewal Monthly Premium Rates or
Premium Equivalent Rates if Waiver
Granted (in dollars)*
Projected Rate Increa
from compliance wit
Limit Restriction (in
Premium by
UlsterGreene ARC
StandaloneHRA
PRA Disclosure Statement
According to the Paperworkinformation collection is 093search existing data resourcimproving this form, please
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 +etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column
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//T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2023%202010.htm[07/20/2011 3:40
rom: Sheer, Jennifer (HHS/OCIIO)
ent: Thursday, December 23, 2010 11:41 AM
o: 'John McHugh'
ubject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application
ollow Up Flag: Follow up
ag Status: Completed
Dear Applicant:
hank you for your information. Your application is now complete and you should receive a determination of yourpplication within 30 days.
hank you.
--------------------------------
ennifer L. O. Sheer
ffice of Consumer Support
ffice of Consumer Information and Insurance Oversight
.S. Department of Health and Human Services
01-492-4487
UlsterGreene:000010
mailto:[email protected]:[email protected] -
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//T|/...RC%20Approval%20Letter%20for%20a%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-30-2010.htm[07/20/2011 3:40
rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 30, 2010 6:00 PM
To: '[email protected]'ubject: Ulster Greene ARC Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010
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 Ulster Greene ARC.HHS has reviewed your application and made its determination. Pleas
ee the attached letter.
lease confirm receipt of this letter by replying to this e-mail.
lease let me know if I can be of further assistance.
incerely,
andy Habit
epartment of Health and Human Services
ffice of Consumer Information and Insurance Oversight
01-492-4175
NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publiclysclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu
r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e
f the law.
UlsterGreene:000011
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rom: Botwinick, Alexandra (HHS/OCIIO)ent: Wednesday, January 12, 2011 11:32 AM
To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Ulster Greene ARC Waiver of the Annual Limits Requirements of PHS Act Section 2711
mportance: High
Attachments: Updated Jan 1 Approval Letter .pdfood Morning,
hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act
ection 2711 for Ulster Greene ARC. HHS has reviewed your application and made its determination. Pleas
ee 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
UlsterGreene:000012
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