superior officers council - redacted bates hw

7/27/2019 Superior Officers Council - Redacted Bates HW

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//C|/...Health%20and%20Welfare%20Fund/WAIVER--Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund.htm[08/04/2011 4:00:0

rom: Gogna, Anubhav ([email protected]) [[email protected]]ent: Tuesday, November 30, 2010 12:22 PM

To: HHS HealthInsurance (HHS)Cc: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected]); Killion, Tammy ([email protected]: WAIVER--Superior Officers Council Health and Welfare Fund

Attachments: Superior Officers Council Welfare Fund Actuary Certification.pdf; Superior Officers Council Welfaund Waiver--FINAL (11-30-10)..pdf

ear Mr. Mayhew,

n behalf of the Superior Officers Council Health and Welfare Fund ( the "Fund"), I am submitting this application for waiver of estricted annual limit under Public Health Services Act 2711, pursuant to OCIIO gulatory Guidance OCIIO 2010-1 an010-1A. The Fund has a per-family annual limit on prescription drug benefits of $ and, as detailed in the attached wapplication and accompanying actuarial projection, imposition of a $750,000 annual ould result in the Fund's insolvency, rastically 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

019470/07]

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.

SupOff:000001

Document obtained by CompleteColorado.com
http://www.groom.com/http://www.groom.com/mailto:[email protected]:[email protected]://www.groom.com/


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Pages 5 through 7 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4

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//C|/...20from%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Correspondence%2012.13.10.htm[08/04/2011 4:00

rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 13, 2010 1:42 PM

To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)

am Lynne Moultrie

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services301) 492-4174

[email protected]

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 disseminated, distribut

copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 13, 2010 1:41 PMo: 'Gogna, Anubhav ([email protected])'c: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected])ubject: RE: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)

hank you for your information. Your application is now complete and you receive a determination of yourpplication within 30 days.

hank you.

am Lynne Moultrie


.S. Department of Health and Human Services

301) 492-4174

[email protected]




rom: Gogna, Anubhav ([email protected]) [mailto:[email protected]]ent: Thursday, December 09, 2010 9:53 AMo: Moultrie, Cam (HHS/OCIIO)c: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected])ubject: RE: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)

ear Ms. Moultrie,

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7/26


hank you for your email regarding the annual limit waiver request that was filed by the Superior Officers Council Health and

Welfare Fund (the "Fund"). As requested, we are attaching the spreadsheet that your office provided, detailing information

pplicable to the Fund's prescription drug benefits, for which the Fund has requested a waiver of the annual limit that is curren

ffect.

n response to your specific questions, please note:

. As detailed in the Fund's 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 147.140; and

. The Fund is not established pursuant to the Taft-Hartley Act, which applies only to benefit plans that arejointly 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 Captains Endowment Association and the Lieutenants

enevolent Association (the "Unions") to provide supplemental benefits -- such as prescription drug coverage -- to collectively

argained employees of New York City who are represented by the Unions. The supplemental benefits provided by the Fund

prescription drug, dental, vision, hearing aid, and death) are not covered by the City of New York's plan for such employees.

ccordingly, the Unions established the Fund to fill in this "gap" in coverage, and to ensure that collectively bargained employe

eceive coverage for these important health benefits. The Fund provides these benefits with contributions from the City, negoti

etween the Unions 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 202.861.5429, and I can be reached at 202.861.2602.

est regards,

nubhav Gogna

Groom Law Group, Chartered



rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 08, 2010 7:47 PMo: Gogna, Anubhav ([email protected])c: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Superior Officers Council Health and Welfare Fund

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 to the 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 with

grandfathering provisions, pursuant to 45 CFR 147.140?

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

SupOff:000007



8/26


n order to complete your application, please provide this information by 5:00 pm, December 10, 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.

am Lynne Moultrie



301) 492-4174

[email protected]

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 disseminated, distribut


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.

SupOff:000008



9/26

//C|/...%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Request%20for%20info%2012.8.10.htm[08/04/2011 4:00:

rom: Moultrie, Cam (HHS/OCIIO)ent: Wednesday, December 08, 2010 7:47 PM

To: [email protected]: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Superior Officers Council Health and Welfare Fund

Attachments: Waiver Application Form 12-8-10.xlsDear Mr. Gogna,


I. Please complete the entire annual limits spreadsheet attached to the 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.






hank you.

am Lynne Moultrie



301) 492-4174

[email protected]




SupOff:000009



10/26

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)

EmailAddress

Type of

Coverage(e.g., Limited

Benefit, HRA,Rx only, Other)

Self-

Insured(Yes/No)

Individual orGroup Policy

Total

Number ofIndividualsCovered 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

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

100 ABCDrive Washington DC 20202

1-800-ABC-1234

[email protected] Limited Benefit Yes Group 2,500 $100,000

Disclosure Statement

ording to the Paperwork Reductio n Act of 1995, no person s are required to respond to a collection of inform ation unless it displays a valid OMB control number . The valid OMB control number fo r 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 inf ormation 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.

SupOff:000010

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


11/26


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)

C

a

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)

RxCopay/Con

SupOff:000011



12/26


idual/ Employee

Employee

contribution(if applicable)

Employer

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

Employee


Employer


Employee


Employer


Projected Rate Increasethat would result from

compliance with $750,000Annual L imit Restric tion

(in do llars)(Average

Premium by Individual)(Difference of Column AT

and AQ divided byColumn AQ)

Access t o

Benefits 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

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

ployee + 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 compliance 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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//C|/...uperior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Request%20for%20info%20response%2012.13.10.htm[08/04/2011 4:00

rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, December 13, 2010 1:42 PM

To: Habit, Sandra (HHS/OCIIO)ubject: FW: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)

Attachments: Superior Officers Council Welfare Fund Waiver Application Form 12-9-10.xls

am Lynne Moultrieffice of Consumer Information and Insurance Oversight


301) 492-4174

[email protected]




rom: Gogna, Anubhav ([email protected]) [mailto:[email protected]]ent: Thursday, December 09, 2010 9:53 AMo: Moultrie, Cam (HHS/OCIIO)c: Mazawey, Lou ([email protected]); Nielsen, Mark ([email protected])ubject: RE: Waiver Application for Superior Officers Council Health and Welfare Fund (019470/07)

ear Ms. Moultrie,

hank you for your email regarding the annual limit waiver request that was filed by the Superior Officers Council Health and

Welfare Fund (the "Fund"). As requested, we are attaching the spreadsheet that your office provided, detailing informationpplicable to the Fund's prescription drug benefits, for which the Fund has requested a waiver of the annual limit that is curren

ffect.

n response to your specific questions, please note:

. As detailed in the Fund's 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 147.140; and

. The Fund is not established pursuant to the Taft-Hartley Act, which applies only to benefit plans that arejointlymaintained

nions and employers, and which are governed by a jointboard of trustees comprising an equal number of employer and union

ustees. Rather, the Fund was established and is maintained by the Captains Endowment Association and the Lieutenants

enevolent Association (the "Unions") to provide supplemental benefits -- such as prescription drug coverage -- to collectivelyargained employees of New York City who are represented by the Unions. The supplemental benefits provided by the Fund

prescription drug, dental, vision, hearing aid, and death) are not covered by the City of New York's plan for such employees.

ccordingly, the Unions established the Fund to fill in this "gap" in coverage, and to ensure that collectively bargained employe

eceive coverage for these important health benefits. The Fund provides these benefits with contributions from the City, negoti

etween the Unions 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 202.861.5429, and I can be reached at 202.861.2602.

est regards,

nubhav Gogna

SupOff:000013



14/26


Groom Law Group, Chartered



rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, December 08, 2010 7:47 PMo: Gogna, Anubhav ([email protected])c: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Superior Officers Council Health and Welfare Fund

Dear Mr. Gogna,


I. Please complete the entire annual limits spreadsheet attached to the 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 do

not 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.





n order to complete your application, please provide this information by 5:00 pm, December 10, 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.

am Lynne Moultrie



301) 492-4174

[email protected]




SupOff:000014



15/26







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.

SupOff:000015



16/26

//C|/...Council%20Health%20and%20Welfare%20Fund%20Annual%20Limit%20Waiver%20Application%20Dec%2020%202010.htm[08/04/2011 4:00

rom: Machado, Juan (HHS/OCIIO)

ent: Monday, December 20, 2010 11:28 AM

o: '[email protected]'

c: Sheer, Jennifer (HHS/OCIIO); '[email protected]'; '[email protected]'

ubject: Superior Officers Council Health and Welfare Fund Annual Limit Waiver Application

ttachments: Waiver Application Form.xls

Dear Mr. Mazawey,


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.


Please confirm whether or not your plan(s) or policy(ies) provide a lifetime limit. Pursuant to Section 2711

the PHS Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the casenon-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limmay add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. your plan does contain a lifetime limit please confirm whether this lifetime limit will be eliminated from yoplan.



hank you.

uan Machado

rogram Analyst


epartment of Health & Human ServicesMD Office: (301) 492-4240


his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distrib

or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

SupOff:000016

http://www.hhs.gov/ociio/regulations/annual_limit_waivers.htmlhttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html


17/26

//C|/...om%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Question%20response%201.14.11.htm[08/04/2011 4:00

rom: Pham, Erica (HHS/OCIIO)ent: Friday, January 14, 2011 11:11 AM

To: Nielsen, Mark ([email protected]); Machado, Juan (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)

ubject: RE: Superior Officers Council Health & Welfare Fundark:

uperior Officers' Council should receive an email today for an approval of the plan. We apologize in the delay in getting the leto the plan. Please let us know if you have any additional questions.

est,rica

rom: Nielsen, Mark ([email protected]) [[email protected]]ent: Thursday, January 13, 2011 10:25 PMo: Machado, Juan (HHS/OCIIO); Pham, Erica (HHS/OCIIO)ubject: RE: Superior Officers Council Health & Welfare Fund

ear Erica,

it possible to get confirmation as to the waiver application for the Superior Officers' Council fund? Any assistance you can

rovide would be most appreciated. Thanks--and please feel free to call me if you have any questions or need anything.

est regards,

Mark C. Nielsen

Mark C. Nielsen / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-5429 /Fax: 202-659-4503

www.Groom.com/ [email protected]

rom: Machado, Juan (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 10, 2011 9:26 AMo: Pham, Erica (HHS/OCIIO)

c: Nielsen, Mark ([email protected])ubject: Superior Officers Council Health & Welfare Fund

i Erica,

have included Mark Nielsen who filed the waiver application for Superior Officers Council Health & Welfare Fund on this

mail. He has yet to receive the status of this particular waiver application. Although our records indicate that a status

pdate was sent, would it be possible to send a follow-up to confirm?

hanks for your help,

uan

uan Machado

rogram Analyst


epartment of Health & Human Services

MD Office: (301) 492-4240NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:



SupOff:000017



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//C|/...om%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Question%20response%201.14.11.htm[08/04/2011 4:00








this communication.

SupOff:000018



19/26


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)

EmailAddress

Type of

Coverage(e.g., Limited

Benefit, HRA,Rx only, Other)

Self-

Insured(Yes/No)

Individual orGroup Policy

Total

Number ofIndividualsCovered by

Policy(include all

dependents

Current

Plan OverallAnnual

Limit (indollars)

periorficers

ouncillth andelfareund Plan 1 New York NY

1/1/2011Plan Year

Mark C.Nielsen;

AnubhavGogna

1701Pennsylvania

Avenue,N.W. Washington DC 20006

202-861-5429; 202-

861-2602 mcn@groom. Limited Benef i t Yes Group None

Disclosure Statement

ording to the Paperwork Reductio n Act of 1995, no person s are required to respond to a collection of inform ation unless it displays a valid OMB control number . The valid OMB control number fo r 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 inf ormation 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.

SupOff:000019



20/26


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

applicabl

C

a

None None None None None None None None None $0.00 $0.00 0.00% $0.00 0.00% $0.00 0.00%

Office VisitCopays/Coinsurance

Hospital InpatientCopay/Coinsurance

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

RxCopay/Con

SupOff:000020



21/26


idual/ Employee

Employee


Employer

contribution

Employee


Employer

contribution

Employee


Employer


Projected Rate Increasethat would result from

compliance with $750,000Annual L imit Restric tion

(in do llars)(Average

Premium by Individual)(Difference of Column AT

and AQ divided byColumn AQ)

Access t o

Benefits 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

pl oye e + F ami ly $0 .00 $0.00 $0.00

Christopher

Monahan Trustee

$0.00

Projected Rate Increase that would result

from compliance 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).

SupOff:000021



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//C|/...D%201%20from%20CCIIO/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Approval%201.14.11.txt[08/04/2011 4:00

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Friday, January 14, 2011 11:07 AMo: [email protected]; Habit, Sandra (HHS/OCIIO)

Cc: [email protected]: Superior Officers Council Health and Welfare Fund Waiver of the

Annual Limits Requirements of PHS Act Section 2711

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdf

Good Morning,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2or Superior Officers Council Health and Welfare Fund. HHS has reviewed your application and made itsetermination. 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

Office of OversightHHS/[email protected]

SupOff:000022



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//C|/...O/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Approval%20receipt%201.14.11.htm[08/04/2011 4:0

rom: Nielsen, Mark ([email protected]) [[email protected]]Sent: Friday, January 14, 2011 11:26 AMo: Pham, Erica (HHS/OCIIO); Machado, Juan (HHS/OCIIO)

Cc: Habit, Sandra (HHS/OCIIO)Subject: Re: Superior Officers Council Health & Welfare Fund

Erica,

We received the approval letter. Thanks to both you and Juan!

Mark C. Nielsen / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-5429 /Fax: 202-659-4503

www.Groom.com/ [email protected]

rom: Pham, Erica (HHS/OCIIO) o: Nielsen, Mark ([email protected]); Machado, Juan (HHS/OCIIO) c: Habit, Sandra (HHS/OCIIO) ent: Fri Jan 14 11:10:59 2011ubject: RE: Superior Officers Council Health & Welfare Fund

ark:

uperior Officers' Council should receive an email today for an approval of the plan. We apologize in the delay in getting the let

o the plan. Please let us know if you have any additional questions.

est,rica

rom: Nielsen, Mark ([email protected]) [[email protected]]ent: Thursday, January 13, 2011 10:25 PMo: Machado, Juan (HHS/OCIIO); Pham, Erica (HHS/OCIIO)ubject: RE: Superior Officers Council Health & Welfare Fund

ear Erica,

it possible to get confirmation as to the waiver application for the Superior Officers' Council fund? Any assistance you canrovide would be most appreciated. Thanks--and please feel free to call me if you have any questions or need anything.

est regards,

Mark C. Nielsen

Mark C. Nielsen / 1701 PennsylvaniaAve., N.W. /Washington, DC 20006 /Phone: 202-861-5429 /Fax: 202-659-4503 www.Groom.com/ [email protected]

rom: Machado, Juan (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 10, 2011 9:26 AM

o: Pham, Erica (HHS/OCIIO)c: Nielsen, Mark ([email protected])ubject: Superior Officers Council Health & Welfare Fund

i Erica,

have included Mark Nielsen who filed the waiver application for Superior Officers Council Health & Welfare Fund on this

mail. He has yet to receive the status of this particular waiver application. Although our records indicate that a status

pdate was sent, would it be possible to send a follow-up to confirm?

hanks for your help,

SupOff:000023

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


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//C|/...O/Superior%20Officers%20Council%20Health%20and%20Welfare%20Fund/Approval%20receipt%201.14.11.htm[08/04/2011 4:0

uan

uan Machado

rogram Analyst


epartment of Health & Human Services

MD Office: (301) 492-4240NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:










this communication.

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