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///co-adshare/...FOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20info%2012.16.10.htm[11/08/2011 11:19

rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 16, 2010 4:07 PM

To: '[email protected]'ubject: Waiver Application - Brevard Achievement Center

Dayle,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:. Please complete the entire annual limits spreadsheet, available at:

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

Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the

ast collective bargaining agreement.

Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying w

the requirements of the Grandfathering Regulation, 45 CFR 147.140?Once this information is received and the application is complete, it will be processed by the Department of Healthnd Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a deci

within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waecision.

hank you,andy

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

[email protected]

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed 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.

BREVARD:000070
http://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlmailto:[email protected]:[email protected]://www.hhs.gov/ociio/regulations/annual_limit_waivers.html


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///co-adshare/...FOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20info%2012.27.10.htm[11/08/2011 11:19

rom: Habit, Sandra (HHS/OCIIO)ent: Monday, December 27, 2010 1:10 PM

To: '[email protected]'ubject: Waiver Application - Brevard Achievement Center

Mr. Olson,

sent you the spreadsheet on December 16, 2010 that would need to be completed in order to complete your application for

revard Achievement Center, unfortunately, I have not heard back from you as of this time. If you have any questions please

ee to contact me.

andy

andy Habit

epartment of Health and Human Services

ffice of Consumer Information and Insurance Oversight

01-492-4175

[email protected]

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly

sclosed 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.

BREVARD:000071
mailto:[email protected]:[email protected]


72/97

///co-adshare/...on/Brevard%20Achievement%20Center/Request%20for%20info%20correspondence%2012.27.10.htm[11/08/2011 11:2

rom: Dayle Olson [[email protected]]Sent: Monday, December 27, 2010 2:58 PMo: Habit, Sandra (HHS/OCIIO)

Subject: Re: Waiver Application - Brevard Achievement Centerandyorry about the delay -I have been away unexpected - but do return to work tomorrow. I will make it mriority in the morning

Dayle

ent from my iPhone

On Dec 27, 2010, at 1:10 PM, "Habit, Sandra (HHS/OCIIO)" wrote:

Mr. Olson,

I sent you the spreadsheet on December 16, 2010 that would need to be completed in order to complete your

application for Brevard Achievement Center, unfortunately, I have not heard back from you as of this time. If you

have any questions please feel free to contact me.

Sandy

Sandy Habit

Department of Health and Human Services

Office of Consumer Information and Insurance Oversight

301-492-4175

[email protected]

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

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

be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosuresmay result in prosecution to the full extent of the law.

Total Control Panel Login

To: [email protected]

From: [email protected]

Message Score: 1 High (60): Pass

My Spam Blocking Level: High Medium (75): Pass

Low (90): Pass

Blockthis sender

Blockhhs.gov

This message was delivered because the content filter score did not exceed your filter level.

BREVARD:000072
mailto:[email protected]:[email protected]://asp-9.reflexion.net/login?domain=bacbrevard.commailto:[email protected]:[email protected]://asp-9.reflexion.net/FooterAction?ver=1&bl-sender-address=1&rID=53559881&aID=77053578https://asp-9.reflexion.net/FooterAction?ver=1&bl-sender-address=1&rID=53559881&aID=77053578https://asp-9.reflexion.net/FooterAction?ver=1&bl-sender-domain=1&rID=53559881&aID=77053578http://hhs.gov/http://hhs.gov/https://asp-9.reflexion.net/FooterAction?ver=1&bl-sender-domain=1&rID=53559881&aID=77053578https://asp-9.reflexion.net/FooterAction?ver=1&bl-sender-address=1&rID=53559881&aID=77053578mailto:[email protected]:[email protected]://asp-9.reflexion.net/login?domain=bacbrevard.commailto:[email protected]:[email protected]


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///co-adshare/...Processing%20Team/Brandon/Brevard%20Achievement%20Center/Correspondence%2012.28.10.htm[11/08/2011 11:20

om: Dayle Olson [[email protected]]

ent: Tuesday, December 28, 2010 5:27 PM

o: Habit, Sandra (HHS/OCIIO)

ubject: Re: Waiver Application - Brevard Achievement Center

ttachments: baccolorlogo.htmndra - -the spreadsheet for the Waiver for the Brevard Achievement Center is nearly complete. Our Benefits Coordinator has

reed to come in tomorrow to finish it for us (she is on Holiday leave). As soon as she finishes the report I will get it to you.ayle Olson

ayle Olson

esidentevard Achievement Center

45 Cogswell Streetockledge, Florida 32955

[email protected]

BREVARD:000073


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///co-adshare/...20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Correspondence%20response%2012.29.10.htm[11/08/2011 11:20

rom: Habit, Sandra (HHS/OCIIO)ent: Wednesday, December 29, 2010 10:08 AMo: 'Dayle Olson'ubject: RE: Waiver Application - Brevard Achievement Center

ayle,

hank you.

andy

om: Dayle Olson [mailto:[email protected]]ent: Tuesday, December 28, 2010 5:27 PMo: Habit, Sandra (HHS/OCIIO)ubject: Re: Waiver Application - Brevard Achievement Center

ndra - -the spreadsheet for the Waiver for the Brevard Achievement Center is nearly complete. Our Benefits Coordinator has

reed to come in tomorrow to finish it for us (she is on Holiday leave). As soon as she finishes the report I will get it to you.ayle Olson

ayle Olson


45 Cogswell Street

ockledge, Florida [email protected]

BREVARD:000074


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///co-adshare/.../Brandon/Brevard%20Achievement%20Center/Request%20for%20info%20response%2012.29.10.htm[11/08/2011 11:2

om: Dayle Olson [[email protected]]

ent: Wednesday, December 29, 2010 1:47 PM

o: Habit, Sandra (HHS/OCIIO)

c: Tere Sulzbach

ubject: Fwd: RE: Waiver Application - Brevard Achievement Center

ttachments: BAC Waiver Application Form.xls; baccolorlogo.htm

ndra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know.oo much snow there???ayle Olson

ayle Olson


45 Cogswell Streetockledge, Florida 32955

[email protected]

>> Tere Sulzbach 12/29/2010 1:11 PM >>>

Sandra,

tached please find the completed spreadsheet.

nswers to questions:

Confirm whether the plan was created pursuant to theft-Hartley Act. If so, please state the expiration of the lastllective bargaining agreement. NO

Please confirm that your plan was in existence before March, 2010, and if so, whether it will be complying with the requirementsthe Grandfathering Regulation, 45 CFR 147.140? YES

ease let us know if you have any questions,ayle

______________onfidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidentivileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using,taining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, p

otify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

ere Sulzbachenefits & Compensationdministrator

BREVARD:000075


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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

dependents

Current

Plan OverallAnnual

Limit (in

evardevement

ter, Inc.

Brevard

Achievement

Center, Inc.Health &

Welfare Plan Rockledge FL 06/01/2000

Teresa

Sulzbach

1845Cogswell

Street Rockledge FL 32955

321-632-

8610 tsulzbach@ba Limited Benefit Yes Group

Disclosure Statement

rding to the Pap erwork Reduction Act of 1995, no person s are required to re spond to a collec tion of informatio n unless it disp lays a valid OMB c ontrol number. The valid OMB contr ol number for thismation collection is 0938-1105. The time required to complete this information collection is estimat ed 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 informatio n 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.

BREVARD:000076


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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)

Office VisitCopays/Coinsurance

Hospital InpatientCopay/Coinsurance

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

BREVARD:000077


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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

Policy

Terminated

Teresa

Sulzbach

Chris Caveness/TPA

Plan Coordinator

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).

BREVARD:000078


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///co-adshare/...ndon/Brevard%20Achievement%20Center/Request%20for%20info%20response%20correspondence%2012.29.10.htm[11/08/2011 11:21

rom: Habit, Sandra (HHS/OCIIO)ent: Wednesday, December 29, 2010 2:28 PMo: 'Dayle Olson'c: 'Tere Sulzbach'ubject: RE: RE: Waiver Application - Brevard Achievement Center

ayle,

hank you so much for your response. I have one question for you, is the information only to be broken down into employee +

amily? There are no other tiers available, i.e. employee only, employee + spouse, etc?

We were lucky this time around, the snow hit further east!

andy

om: Dayle Olson [mailto:[email protected]]ent: Wednesday, December 29, 2010 1:47 PMo: Habit, Sandra (HHS/OCIIO)c: Tere Sulzbachubject: Fwd: RE: Waiver Application - Brevard Achievement Center

ndra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know.

oo much snow there???ayle Olson

ayle Olsonesident

evard Achievement Center45 Cogswell Street

ockledge, Florida 32955

[email protected]

>> Tere Sulzbach 12/29/2010 1:11 PM >>>Sandra,





BREVARD:000079


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BREVARD:000080


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///co-adshare/...20Team/Brandon/Brevard%20Achievement%20Center/Renewal%20effective%20date%20question%2012.29.10.htm[11/08/2011 11:21:0

rom: Habit, Sandra (HHS/OCIIO)ent: Wednesday, December 29, 2010 2:31 PMo: 'Dayle Olson'ubject: RE: RE: Waiver Application - Brevard Achievement Center

ayle,

ne last question, what is the renewal effective date?

hanks,

andy

om: Dayle Olson [mailto:[email protected]]ent: Wednesday, December 29, 2010 1:47 PMo: Habit, Sandra (HHS/OCIIO)c: Tere Sulzbachubject: Fwd: RE: Waiver Application - Brevard Achievement Center



ayle Olsonesident









BREVARD:000081


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///co-adshare/...20Team/Brandon/Brevard%20Achievement%20Center/Renewal%20effective%20date%20question%2012.29.10.htm[11/08/2011 11:21:0




BREVARD:000082


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///co-adshare/.../DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Question%20response%2012.29.10.txt[11/08/2011 11:21

rom: Tere Sulzbach [[email protected]]ent: Wednesday, December 29, 2010 2:47 PMo: Habit, Sandra (HHS/OCIIO)ubject: RE: RE: Waiver Application - Brevard Achievement Center

Hello Ms. Habit,

Yes. We only have two tiers: employee and dependents.

Have a great day!ere

______________Confidentiality Notice: This communication, along with any attachments or documents, may contain information ts confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, yore prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient.ou are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components ohis communication. Thank you.

ere Sulzbach

enefits & CompensationAdministrator

>> "Habit, Sandra (HHS/OCIIO)" 12/29/2010 2:27 PM >>>Dayle,

hank you so much for your response. I have one question for you, is the information only to be broken down intomployee + family? There are no other tiers available, i.e. employee only, employee + spouse, etc?

We were lucky this time around, the snow hit further east!andy

_______________________________rom: Dayle Olson [mailto:[email protected]]ent: Wednesday, December 29, 2010 1:47 PMo: Habit, Sandra (HHS/OCIIO)

Cc: Tere Sulzbachubject: Fwd: RE: Waiver Application - Brevard Achievement Center

andra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please lenow.oo much snow there???

Dayle Olson

cid:[email protected]]

Dayle Olsonresidentrevard Achievement Center845 Cogswell Street

Rockledge, Florida [email protected]

BREVARD:000083


84/97

///co-adshare/.../DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Question%20response%2012.29.10.txt[11/08/2011 11:21

>> Tere Sulzbach 12/29/2010 1:11 PM >>>Hi Sandra,

Attached please find the completed spreadsheet.

Answers to questions:I.

Confirm whether the plan was created pursuant to theaft-Hartley Act. If so, please state the expiration of the lastollective bargaining agreement. NO

Please confirm that your plan was in existence before March3, 2010, and if so, whether it will be complying with the requirementsf the Grandfathering Regulation, 45 CFR 147.140? YES

lease let us know if you have any questions,Dayle


ere Sulzbachenefits & Compensation

Administrator

BREVARD:000084


85/97

///co-adshare/...es/DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Contact%20question%2012.29.10.txt[11/08/2011 11:21

rom: Habit, Sandra (HHS/OCIIO)ent: Wednesday, December 29, 2010 3:18 PMo: 'Tere Sulzbach'ubject: RE: RE: Waiver Application - Brevard Achievement Center

ere,Would it be possible for you to contact me at 301-492-4175?

hanks,

andy

----Original Message-----rom: Tere Sulzbach [mailto:[email protected]]ent: Wednesday, December 29, 2010 2:47 PMo: Habit, Sandra (HHS/OCIIO)ubject: RE: RE: Waiver Application - Brevard Achievement Center

Hello Ms. Habit,

Yes. We only have two tiers: employee and dependents.

Have a great day!ere


ere Sulzbach

enefits & CompensationAdministrator

>> "Habit, Sandra (HHS/OCIIO)" 12/29/2010 2:27 PM >>>Dayle,

hank you so much for your response. I have one question for you, is the information only to be broken down intomployee + family? There are no other tiers available, i.e. employee only, employee + spouse, etc?

We were lucky this time around, the snow hit further east!andy

_______________________________rom: Dayle Olson [mailto:[email protected]]ent: Wednesday, December 29, 2010 1:47 PMo: Habit, Sandra (HHS/OCIIO)

Cc: Tere Sulzbachubject: Fwd: RE: Waiver Application - Brevard Achievement Center

andra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please lenow.oo much snow there???

BREVARD:000085


86/97

///co-adshare/...es/DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Contact%20question%2012.29.10.txt[11/08/2011 11:21

Dayle Olson

cid:[email protected]]

Dayle Olsonresidentrevard Achievement Center845 Cogswell Street

Rockledge, Florida 32955

[email protected]

>> Tere Sulzbach 12/29/2010 1:11 PM >>>Hi Sandra,

Attached please find the completed spreadsheet.

Answers to questions:I.

Confirm whether the plan was created pursuant to theaft-Hartley Act. If so, please state the expiration of the lastollective bargaining agreement. NO

Please confirm that your plan was in existence before March3, 2010, and if so, whether it will be complying with the requirementsf the Grandfathering Regulation, 45 CFR 147.140? YES

lease let us know if you have any questions,Dayle



Administrator

BREVARD:000086


87/97

///co-adshare/...sing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20additional%20info%2012.29.10.htm[11/08/2011 11:21

rom: Habit, Sandra (HHS/OCIIO)ent: Wednesday, December 29, 2010 3:37 PMo: 'Tere Sulzbach'ubject: FW: RE: Waiver Application - Brevard Achievement Center

ttachments: BAC Waiver Application Form.xls

ere,

s discussed, please fill out the data for the dependents.

hank you,

andy

om: Dayle Olson [mailto:[email protected]]ent: Wednesday, December 29, 2010 1:47 PMo: Habit, Sandra (HHS/OCIIO)c: Tere Sulzbach

ubject: Fwd: RE: Waiver Application - Brevard Achievement Center



ayle Olsonesident








BREVARD:000087


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BREVARD:000088


89/97


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)

evardevement

ter, Inc.

Brevard

Achievement

Center, Inc.Health &


Teresa

Sulzbach

1845Cogswell


321-632-


evard

evement

ter, Inc.

Brevard

Achievement

Center, Inc.

Health &


Teresa

Sulzbach

1845

Cogswell


321-632-


Disclosure Statement

rding to the Pap erwork Reduction Act of 1995, no person s are required to re spond to a collec tion of informatio n unless it disp lays a valid OMB c ontrol number. The valid OMB contr ol number for this

mation collection is 0938-1105. The time required to complete this information collection is estimat ed 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 informatio n 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.

BREVARD:000089
mailto:[email protected]:[email protected]:[email protected]:[email protected]


90/97


Maternity/

Mental Health/

Substance Rehabilitative/ Preventive/ Plan

Copay (if

applicablCoinsuranc

e (if

Copay (if

applicabl

Coinsurance (if

applicablCopay (if

applicabl

Coinsurance (if

applicablCopay (if

applicabl

Current Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit) Copay/CoOffice Visit

Copays/CoinsuranceHospital Inpatient

Copay/CoinsuranceEmergency Room

Copay/Coinsurance

BREVARD:000090


91/97


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

Policy

Terminated

Teresa

Sulzbach

Chris Caveness/TPA

Plan Coordinator

Policy

Terminated

Teresa

Sulzbach

Chris Caveness/TPA

Plan Coordinator

Current Monthly Premium Rates orPremium Equivalent Rates (in dollars)*:rance

Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted

(in dollars)*

Projected Rate Increase that would result

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

Individual)*

* 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/...cessing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20info%20response%2012.30.10.txt[11/08/2011 11:22

rom: Tere Sulzbach [[email protected]]ent: Thursday, December 30, 2010 11:06 AMo: Habit, Sandra (HHS/OCIIO)

Cc: Dayle Olsonubject: Waiver Application - Brevard Achievement Center

Attachments: BAC Waiver Application Form.xls

Hello Ms. Habit

Here is the worksheet with a second row added containing the maximum allowed for dependents.

We have employees who have dependent coverage and a total of dependents.lease let us know if you need anything further.

Regards,ere



Administrator

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///co-adshare/...0-%20Torres/DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Approval%201.12.11.htm[11/08/2011 11:22

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Wednesday, January 12, 2011 11:20 AM

To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Brevard Achievement Center, Inc. Waiver of the Annual Limits Requirements of PHS Act Section 2711

mportance: High

Attachments: June 1 .pdfood Morning,

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

ection 2711 forBrevard Achievement Center, Inc.. HHS has reviewed your application and made its

etermination. Please see the attached letter.

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

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

incerely,

Alexandra Botwinick

ffice of Oversight

HHS/[email protected]

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BREVARD:000095


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rom: Botwinick, Alexandra (HHS/OCIIO)ent: Thursday, January 13, 2011 9:01 AMo: Habit, Sandra (HHS/OCIIO)ubject: FW: Brevard Achievement Center, Inc. Waiver of the Annualimits Requirements of PHS Act Section 2711

Alexandra Botwinick

Office of OversightHHS/OCIIO301) 492-4177

[email protected]

----Original Message-----rom: Tere Sulzbach [mailto:[email protected]]

ent: Thursday, January 13, 2011 8:57 AMo: Botwinick, Alexandra (HHS/OCIIO)ubject: Re: Brevard Achievement Center, Inc. Waiver of the Annual Limits Requirements of PHS Act Section 27

Good Morning Ms. Botwinick,

his is to confirm your e-mail.

hank you very much.ere



Administrator

>> "Botwinick, Alexandra (HHS/OCIIO)" 1/12/2011 11:19 AM >>>Good Morning,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2or Brevard Achievement Center, Inc.. HHS has reviewed your application and made its determination. Please seettached letter.

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

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

incerely,

Alexandra Botwinick

Office of OversightHHS/[email protected]

brevard achievement center - redacted hwm

Documents