Gilster-Mary Lee Corporation - Redacted HWM

7/27/2019 Gilster-Mary Lee Corporation - Redacted HWM

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///co-adshare/...aivers%20-%20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/WAIVER.htm[11/14/2011 11:02:0

rom: Russell Brown [[email protected]]ent: Tuesday, November 30, 2010 5:35 PM

To: HHS HealthInsurance (HHS)Cc: 'Bill Pohlman'; 'Jim Ringland'; 'Marty Joseph'ubject: WAIVER

Attachments: Signed Waiver Attestation.pdf; Waiver Annual Limits.pdfttached is an Annual Limits waiver application with supporting documentation. I apologize for the late timing in filing the reque

s this is a 1/1/2011 Plan. It took us longer to analyze the impact than expected. If there is additional information needed or

arifications on information submitted, I will be glad to assist.

hank you for your review

ussell Brown

irector Market Services

enefit Administrative Systems, LLC (Claim Administrator for Plan)

08-647-3417

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///co-adshare/...OI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%2012.18.10.htm[11/14/2011 11:02

rom: Andrews, Jane (HHS/OCIIO)ent: Saturday, December 18, 2010 4:58 PM

To: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)

ubject: Your application for a waiver of annual limits requirements

Attachments: Waiver Application Form.xlshank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act

PHS Act) Section 2711. In order to expedite your application, please provide the following information:

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

II. In addition, if you did not include the following information in your application and is applicable, pleaseprovide 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. If is is, please provide the date the

collective bargaining agreement will expire.

Confirm that your plan is either self-insured or fully insured.

If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance,

please submit that with the spreadsheet as a separate attachment.

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 and feel free to contact me with questions.

ane W. Andrews

CIIO

501 Wisconsin Aveethesda, MD 20814

01-492-4122 (desk)

02-536-6779 (Blackberry)

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal governmuse only and must not be disseminated, distributed, or copied to persons not authorized to receive the informatio

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

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ANNUAL LIMIT WAIVER APPLICATION 2010

al

Waiverest

c ante

Policy Name

(use a newrow for each

policyapplication)

Applic ant

(Plan/ PolicySitus) City

Applic ant

(Plan/Policy

Situs)State

Plan/ Policy

Effective Date(mm/dd/yyyy)

ContactName

StreetAddress City State Zip Code

PhoneNumber

(includingarea code)

EmailAddres s

Type of

Coverage(e.g., Limited

Benefit, HRA,Rx only, Other)

Self-

Insured(Yes/No)

Individual orGroup Policy

TotalNumber of

IndividualsCovered by

Policy(include all

dependentscovered)

Current

Plan OverallAnnual

Limit (indollars)

plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe

100 ABCDrive Washington DC 20201

1-800-ABC-1234

[email protected] Limited Benefit Yes Group 4,000 $100,000



1-800-ABC-1234


Disclosure Statement

ording to the Paperwork Reductio n Act of 1995, no per sons are required to respond to a collection of infor mation unless it displays a valid OMB control number. The valid OMB control number f or thismation collection is 0938-1105. The time required to complete this information collection is estimated 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 in formation collection. 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.

GLISTER:000022
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn

Mental Health/

SubstanceAbuse

Rehabilitative/Devices

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

PlanDeductible

Copay (if

applicable)

Coinsuranc

e (ifapplicable)

Copay (if

applicable)

Coinsurance (if

applicable)

Copay (if

applicable)

Coinsurance (if

applicable)

Copay (if

applicable)

None None None None None None None None None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00

None None None None None None None None None $3,000.00 $1,000.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00

Office VisitCopays/Coinsurance

Hospital InpatientCopay/Coinsurance

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

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suran

e (ifcable)

Individual/ EmployeeTier*

Employee

contribution(if applicable)

Employer

contribution(i f ap pl ic ab le) To tal

Employee


Employer

contribution( if ap pl ic ab le) To tal

Employee


Employer


Projected Rate Increasethat would result from

compliance with $750,000

Annual L imit Rest rict ion(in doll ars)(Average

Premium by Individual)(Difference of Column AT

and AQ divided byColumn AQ)

Access t oBenefits that

would resultfrom

compliancewith $750,000Annual L imit

Restriction(describe

briefly in cellor in a

PlanAdmini strator/ CEO

of HealthInsuranc

e IssuerName

Title of Individual

ProvidingAttest ation

one Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800.00 $925.00 21.71% None Jane Doe Plan Administrator

one Employee + Family $105.00 $1,100.00 $1,205.00 $115.00 $1,150.00 $1,265.00 $150.00 $1,400.00 $1,550.00 22.53% None Jane Doe Plan Administrator

Projected Rate Increase that would result

from c ompliance with $750,000 Annual LimitRestriction (in do llars) (Average Premium by

Individual)*Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:rance

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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///co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:2

rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 10, 2011 10:49 AM

To: 'Russell Brown'Cc: Habit, Sandra (HHS/OCIIO)

ubject: RE: Your application for a waiver of annual limits requirementshank you. The application for Gilster-Mary Lee Corporation Group is now complete. The applicant should be hearing soon w

etermination.

ane W. Andrews

CIIO501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





rom: Russell Brown [mailto:[email protected]]ent: Monday, January 10, 2011 8:51 AMo: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limits requirements

he Plan is not Taft Hartley and it does not plan on maintaining Grandfather status

rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Friday, January 07, 2011 4:36 PMo: 'Russell Brown'ubject: RE: Your application for a waiver of annual limits requirements

have incorporated the spreadsheet and I have the data I need for that. However, do you have answer to the questions below

bout whether you are a Taft Hartley plan, and if so when does the cba expire, and your compliance with the grandfather

egulation.

hanks.

ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





rom: Russell Brown [mailto:[email protected]]ent: Tuesday, December 21, 2010 3:35 PMo: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limits requirements

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ttached is the waiver application and a copy of the attestation submitted in late November 2010.

hank you for your assistance

ussell Brown

rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Saturday, December 18, 2010 3:58 PMo: Andrews, Jane (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: Your application for a waiver of annual limits requirements

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:












ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)




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///co-adshare/...cessing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%20response%201.4.11.htm[11/14/2011 11:02

rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 10, 2011 10:59 AM

To: Habit, Sandra (HHS/OCIIO)ubject: FW: Your application for a waiver of annual limits requirements

Attachments: Waiver Application Form.xls; signed waiver attestation 2.pdfpologize if this is a dupe, but I dont see that I forwarded it to be file in Gilster-Mary Lee Corpor file.

ane W. Andrews

CIIO501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





rom: Russell Brown [mailto:[email protected]]ent: Tuesday, January 04, 2011 3:46 PMo: Andrews, Jane (HHS/OCIIO)ubject: FW: Your application for a waiver of annual limits requirements

rom: Russell Brown [mailto:[email protected]]ent: Tuesday, December 21, 2010 2:35 PMo: 'Andrews, Jane (HHS/OCIIO)'ubject: RE: Your application for a waiver of annual limits requirements

ttached is the waiver application and a copy of the attestation submitted in late November 2010.

hank you for your assistance

ussell Brown

rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Saturday, December 18, 2010 3:58 PMo: Andrews, Jane (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: Your application for a waiver of annual limits requirements

hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act

PHS Act) Section 2711. In order to expedite your application, please provide the following information:



GLISTER:000028


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///co-adshare/...cessing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%20response%201.4.11.htm[11/14/2011 11:02










ane W. Andrews

CIIO

501 Wisconsin Ave

ethesda, MD 20814

01-492-4122 (desk)





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al

Waiverest

c ante

Policy Name

(use a newrow for each

policyapplication)

Applic ant

(Plan/ PolicySitus) City

Applic ant

(Plan/Policy

Situs)State

Plan/ Policy

Effective Date(mm/dd/yyyy)

ContactName

StreetAddress City State Zip Code

PhoneNumber

(includingarea code)

EmailAddres s

Type of

Coverage(e.g., Limited

Benefit, HRA,Rx only, Other)

Self-

Insured(Yes/No)

Individual orGroup Policy

TotalNumber of

IndividualsCovered by

Policy(include all

dependentscovered)

Current

Plan OverallAnnual

Limit (indollars)



1-800-ABC-1234




1-800-ABC-1234


Lee Corpporation Grou Chester IL 01/01/2011 Karen Lowry 1037 State St Chester IL 62233 618-826-2361 gilstermaryle other Yes Group Lee Corpporation Grou Chester IL 01/01/2011 Karen Lowry 1037 State St Chester IL 62233 618-826-2361 gilstermaryle other Yes Group

Disclosure Statement

ording to the Paperwork Reductio n Act of 1995, no per sons are required to respond to a collection of infor mation unless it displays a valid OMB control number. The valid OMB control number f or thismation collection is 0938-1105. The time required to complete this information collection is estimated 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 in formation collection. 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.

GLISTER:000030
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn

Mental Health/

SubstanceAbuse

Rehabilitative/Devices

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

PlanDeductible

Copay (if

applicable)

Coinsuranc

e (ifapplicable)

Copay (if

applicable)

Coinsurance (if

applicable)

Copay (if

applicable)

Coinsurance (if

applicable)

Copay (if

applicable)

None None None None None None None None None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00

Office VisitCopays/Coinsurance

Hospital InpatientCopay/Coinsurance

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

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suran

e (ifcable)

Individual/ EmployeeTier*

Employee


Employer


Employee


Employer

contribution( if ap pl ic ab le) To tal

Employee


Employer


Projected Rate Increasethat would result from

compliance with $750,000

Annual L imit Rest rict ion(in doll ars)(Average

Premium by Individual)(Difference of Column AT

and AQ divided byColumn AQ)

Access t oBenefits that

would resultfrom

compliancewith $750,000Annual L imit

Restriction(describe

briefly in cellor in a

PlanAdmini strator/ CEO

of HealthInsuranc

e IssuerName

Title of Individual

ProvidingAttest ation

one Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800.00 $925.00 21.71% None Jane Doe Plan Administrator

None Jane Doe Plan Admin is trator

None chael Wed Plan Administrator

None chael Wed Plan Administrator

Projected Rate Increase that would result

from c ompliance with $750,000 Annual LimitRestriction (in do llars) (Average Premium by

Individual)*Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:rance

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).

GLISTER:000032


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///co-adshare/...-%20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Approval%201.31.11.htm[11/14/2011 11:02

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Monday, January 31, 2011 9:26 AM

To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Gilster-Mary Lee Corporation Waiver of the Annual Limits Requirements 1-31-2011

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 forGilster-Mary Lee Corporation, Group Health Plan.HHS has reviewed your application andmade 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.

Alexandra Botwinick

ffice of Oversight

HHS/[email protected]

GLISTER:000034
mailto:[email protected]:[email protected]


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Documents

Gilster-Mary Lee Corporation - Redacted HWM