Communication Workers L1180 - Redacted HW

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//O|/Joseph/Communications%20Workers%20of%20America%20Local%201180/Approval%2012.21.10.htm[10/31/2011 12:31:46 PM]

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Tuesday, December 21, 2010 2:08 PMTo: '[email protected]'; '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Communications Workers of America, Local 1180 Security Benefits Fund Approval Letter for a Waiver o

he Annual Limits Requirements 12-21-2010

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdfood Afternoon,

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

ection 2711 forCommunications Workers of America, Local 1180 Security Benefits Fund. HHS has review

our application 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

HHS/[email protected]

CWA L1180:000001
mailto:[email protected]:[email protected]


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//O|/Joseph/Communications%20Workers%20of%20America%20Local%201180/Approval%20confirmation%2012.21.10.htm[10/31/2011 12:31:46 PM

rom: Gogna, Anubhav ([email protected]) [[email protected]]ent: Tuesday, December 21, 2010 2:16 PM

To: Botwinick, Alexandra (HHS/OCIIO); Nielsen, Mark ([email protected])Cc: Habit, Sandra (HHS/OCIIO); Mazawey, Lou ([email protected])

ubject: RE: Communications Workers of America, Local 1180 Security Benefits Fund Approval Letter for a Waif the Annual Limits Requirements 12-21-2010

ollow Up Flag: Follow up

lag Status: RedMs. Botwinick,

his is to confirm receipt of your email with respect to the approval of the application for a Waiver of the Annual Limits

equirements for the Communications Workers of America, Local 1180 Security Benefits Fund. Thank you.

est regards,

nu Gogna

Anubhav Gogna / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-2602 /Fax: 202-659-4503 www.Groom.com/[email protected]

rom: Botwinick, Alexandra (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, December 21, 2010 2:08 PMo: Nielsen, Mark ([email protected]); Gogna, Anubhav ([email protected])c: Habit, Sandra (HHS/OCIIO)ubject: Communications Workers of America, Local 1180 Security Benefits Fund Approval Letter for a Waiver of the Annual Limequirements 12-21-2010mportance: High

ood Afternoon,






incerely,

Alexandra Botwinick

ffice of Oversight


CWA L1180:000002
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.groom.com/


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//O|/Joseph/Communications%20Workers%20of%20America%20Local%201180/Approval%20confirmation%2012.21.10.htm[10/31/2011 12:31:46 PM

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 U.S. 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 Revenode, and such advice cannot be quoted or referenced to promote or market to another party any transaction or matter addres

this communication.

CWA L1180:000003


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//O|/Joseph/Communications%20Workers%20of%20America%20Local%201180/Approval%20receipt%2012.21.10.htm[10/31/2011 12:31:47 PM]

rom: Gogna, Anubhav ([email protected]) [[email protected]]ent: Tuesday, December 21, 2010 2:16 PM

To: Botwinick, Alexandra (HHS/OCIIO); Nielsen, Mark ([email protected])Cc: Habit, Sandra (HHS/OCIIO); Mazawey, Lou ([email protected])ubject: RE: Communications Workers of America, Local 1180 Security Benefits Fund Approval Letter for a Waif 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 Communications Workers of America, Local 1180 Security Benefits Fund. Thank you.

est regards,

nu Gogna

Anubhav Gogna / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-2602 /Fax: 202-659-4503

www.Groom.com/[email protected]

rom: Botwinick, Alexandra (HHS/OCIIO) [mailto:[email protected]]ent: Tuesday, December 21, 2010 2:08 PMo: Nielsen, Mark ([email protected]); Gogna, Anubhav ([email protected])c: Habit, Sandra (HHS/OCIIO)ubject: Communications Workers of America, Local 1180 Security Benefits Fund Approval Letter for a Waiver of the Annual Limequirements 12-21-2010mportance: High

ood Afternoon,






incerely,

Alexandra Botwinick

ffice of Oversight


CWA L1180:000004
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.groom.com/


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//O|/Joseph/Communications%20Workers%20of%20America%20Local%201180/Approval%20receipt%2012.21.10.htm[10/31/2011 12:31:47 PM]

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 U.S. 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.

CWA L1180:000005


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//O|/...0America%20Local%201180/Communications%20Workers%20of%20America%20Local%201180%20Security%20Benefi.htm[10/31/2011 12:31

rom: Records, Joseph (HHS/OCIIO)

ent: Tuesday, December 07, 2010 5:44 PM

o: '[email protected]'

c: Sheer, Jennifer (HHS/OCIIO)

ubject: Communications Workers of America, Local 1180 Security Benefits Fund Annual Limits

Waiver Request

ttachments: Waiver Application Form.xls

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

II. In addition, please provide the following information:

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

grandfathering provisions, pursuant to 45 CFR 147.140?

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

n order to complete your application, please provide this information by 5:00 pm, December 8, 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 3

ays 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, N.W.

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

CWA L1180:000006


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ANNUAL LIMIT WAIVER APPLICATION 2010

alWaiver

estc ante

Policy Name(use a new

row for eachpolicyapplication)

Applic ant(Plan/ PolicySitus) City

Applic ant(Plan/

PolicySitus)State

Plan/ PolicyEffective Date(mm/dd/yyyy)

ContactName

StreetAddress City State Zip Code

Phone

Number(includingarea code)

EmailAddres s

Type ofCoverage

(e.g., LimitedBenefit, HRA,

Rx only, Other)

Self-Insured(Yes/No)

Individual orGroup Policy

Total

Number ofIndividuals

Covered byPolicy

(include alldependents

covered)

CurrentPlan Overall

AnnualLimit (indollars)

municati

Workers

merica,

al 1180

curity

nefits

und Plan 1 New York NY

1/1/2011

Plan Year

Mark C.

Nielsen;

Anubhav

Gogna

1701

Pennsylvania

Avenue,

N.W. Washington DC 20006

202-861-

5429; 202-

861-2602 mcn@groom

Disclosure Statement

rding to the Pap erwork Reduction Act of 1995, no person s are required to re spond to a collect ion of informatio n unless it disp lays a valid OMB c ontrol number. The valid OMB contro l number for thismation collection is 0938-1105. The time required to complete this information collection is estimate d to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions,ch existing data resources, gather the data needed, and complete and review the information collec tion. If you have comments concerning the accuracy of the time estimate(s ) or suggestions foroving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CWA L1180:000007


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CWA L1180:000008


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mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn

Mental Health/Substance

AbuseRehabilitative/

DevicesPreventive/Wel ln es s Pr es cr ip ti on

PlanDeductible

Copay (ifapplicabl

e)

Coinsurance (if

applicable)

Copay (ifapplicabl

e)

Coinsura

nce (ifapplicabl

e)

Copay (ifapplicabl

e)

Coinsura

nce (ifapplicabl

e)

Copay (ifapplicabl

e)

C

a

Office Visit

Copays/Coinsurance

Hospital Inpatient

Copay/Coinsurance

Emergency Room

Copay/CoinsuranceCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)

Rx

Copay/Con

CWA L1180:000009


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idual/ EmployeeEmployee

contributionEmployer

contributionEmployee


contributionEmployee


contribution

Projected Rate Increase

that would result fromcompliance with $750,000Annual L imit Rest rict ion

(in do llars)(AveragePremium by Individual)

(Difference of Column ATand AQ divided by

Access t o

Benefits thatwould result

fromcompliance

with $750,000

Annual L imitRestriction

(describebriefly in cell

PlanAdmini str

ator/ CEOof Health

Insurance IssuerName

Title of IndividualProviding

Attest ation

ployee + Family Dwight R.Kearns Fund Administrator

Projected Rate Increase that would resultfrom compli ance with $750,000 Annual LimitRestriction (in d ollars) (Average Premium by

Individual)*

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted

(in dollars)*

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums are a range based on years of service or age) and by tier (Employee, Employee + Spouse, Employee + Child, Family,etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).

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rom: Gogna, Anubhav ([email protected]) [[email protected]]ent: Wednesday, November 24, 2010 9:18 AM

To: HHS HealthInsurance (HHS)Cc: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected]); Killion, Tammy ([email protected]: WAIVER--Communications Workers of America Local 1180 Security Benefits Fund

Attachments: Local 1180 Welfare Fund Waiver--FINAL (11-23-10).doc.pdf; Local 1180 Projections.pdf

ear Mr. Mayhew,

n behalf of the Communications Workers of America Local 1180 Security Benefits Fund (the "Fund"), I am submitting thispplication for waiver of the restricted annual limit under Public Health Services Act 2711, pursuant to OCIIO ulatoryuidance OCIIO 2010-1 and 2010-1A. The Fund has a per-family annual limit on prescription drug benefits of and, asetailed in the attached waiver application and accompanying actuarial projection, imposition of a $750,000 an wouldesult in the Fund's insolvency, or drastically reduced access to benefits for those currently covered by the Fund.

We appreciate your consideration of the Fund's request. Please let Lou Mazawey, Mark Nielsen or me know if you have anyuestions or need anything else. Lou can be reached at 202.861.6608, Mark can be reached at at 202.861.5429 and I can beeached at 202.861.2602.

est regards,

nubhav Gogna

019470/03]

Anubhav Gogna / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-2602 /Fax: 202-659-4503

www.Groom.com/[email protected]

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 U.S. 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.
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/

Documents

Communication Workers L1180 - Redacted HW