Service Employees 32BJ North - Redacted Bates HW

file:///T|/...es%2032BJ %20North%20Health%20Benefit%20Plan/Service%20Employees%2032BJ %20-%20FOIA%20Working/Waiver.
htm[08/12/2011 2:10:39 PM]

From: Gabriele Schroeder [gschroeder@32BJFUNDS.COM]
Sent: Wednesday, December 01, 2010 5:17 PM
To: HHS HealthInsurance (HHS); OCIIO Oversight
Subject: Waiver
Attachments: NHBF Waiver Application 2010 12-01 with SPD.pdf

Follow Up Flag: Follow up
Flag Status: Flagged

Service Employees 32BJ North Health Benefit Plan Application for Waiver of Annual Limit Requirement of the Public Health
Service Act Section 2711

Gabriele Schroeder
Executive Assistant to Susan Cowell
Service Employees 32BJ North Health Benefit Fund
101 Avenue of the Americas
New York, NY 10013

Tel: (212) 388-3534
Fax: (212)388-2185
E-mail: gschroeder@32bjfunds.com

Service 32BJN:000001
Document obtained by CompleteColorado.com
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Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
Ex.
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Ex. 4
Ex. 4
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file:///T|/...alth%20Benefit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Request%20for%20info%2012.18.10.htm[08/12/2011 2:10:40 PM]
From: Andrews, Jane (HHS/OCIIO)
Sent: Saturday, December 18, 2010 4:58 PM
To: Andrews, Jane (HHS/OCIIO)
Cc: Habit, Sandra (HHS/OCIIO)
Subject: Your application for a waiver of annual limits requirements
Attachments: Waiver Application Form.xls
Thank 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 spreadsheet
to this email address as an attachment. We will only be able to process spreadsheets that are fully complete
(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain to
your plan, please write None, and/or provide an explanation regarding why you are unable to complete
that particular cell in a separate document.

II. In addition, if you did not include the following information in your application and is applicable, 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. 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.

In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once this
information is received and the application is complete, it will be processed by the Department of Health and Human
Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30
days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision.

Thank you and feel free to contact me with questions.

Jane W. Andrews
OCIIO
7501 Wisconsin Ave
Bethesda, MD 20814
301-492-4122 (desk)
202-536-6779 (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 government
use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.
Unauthorized disclosure may result in prosecution to the full extent of the law.

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file:///T|/...fit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Request%20for%20info%20response%2012.21.10.htm[08/12/2011 2:10:40 PM]
From: Gabriele Schroeder [gschroeder@32BJFUNDS.COM]
Sent: Tuesday, December 21, 2010 3:15 PM
To: Andrews, Jane (HHS/OCIIO)
Cc: Habit, Sandra (HHS/OCIIO); Susan Cowell; 'Howard M. Bard'
Subject: RE: Your application for a waiver of annual limits requirements
Attachments: 1-332329-4203_01_Revised_Annual_Waiver_Spreadsheet.xls; 1-332711-
SEIU_32BJ_North_Health_Benefit_Fund_Annual_Limit_Waiver_Attachment.pdf; NHBF Waiver Attestation 2010 12-
01.pdf
On behalf of the trustees of the Service Employees 32BJ North Health Benefit Fund and Susan Cowell, please note the
following:

I. Completed spreadsheet is attached.
II. Please see our answers below:

Thank you,

Gabriele Schroeder
Executive Assistant to Susan Cowell, Executive Director
New York, NY 10013

Tel: (212) 388-3534
Fax: (212)388-2185

From: Andrews, J ane (HHS/OCIIO) [mailto:J ane.Andrews@hhs.gov]
To: Andrews, J ane (HHS/OCIIO)




grandfathering provisions, pursuant to 45 CFR 147.140? YES

collective bargaining agreement will expire. YES, This is a multiemployer plan. Please see the attachment for
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file:///T|/...fit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Request%20for%20info%20response%2012.21.10.htm[08/12/2011 2:10:40 PM]
information regarding the staggered expiration dates of the collective bargaining agreements.

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

please submit that with the spreadsheet as a separate attachment. Attestation was submitted with application.
We have attached a copy to this e-mail.



Jane W. Andrews
OCIIO
7501 Wisconsin Ave
Bethesda, MD 20814
301-492-4122 (desk)


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Annual
Limit Waiver
Request
Applicant
Name
Policy Name
(use a new
row for each
policy
application)
Applicant
(Plan/ Policy
Situs) City
Applicant
(Plan/
Policy
Situs)
State
Plan/ Policy
Effective Date
(mm/dd/yyyy)
Contact
Name
Street
Address City State Zip Code
Phone
Number
(including
area code)
Email
Address
Type of
Coverage
(e.g., Limited
Benefit, HRA,
Rx only, Other)
Self-
Insured
(Yes/No)
Individual or
Group Policy
Total
Number of
Individuals
Covered by
Policy
(include all
dependents
covered)
Current
Plan Overall
Annual
Limit (in
dollars)
Service
Employees
32BJ North
Service
Employees
32BJ North 101 Avenue scowell@32
Health
Benefit Fund
Health Benefit
Fund New Rochelle NY 01/01/2011
Susan
Cowell
of the
Americas New York NY 10013
(212) 388-
2104
BJ FUNDS.C
OM Other Yes Group
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 valid OMB control number for this
information 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,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving 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
Request
Applicant
Name
Policy Name
(use a new
row for each
policy
application)
Service
Employees
32BJ North
Service
Employees
32BJ North
Ambulatory Emergency Hospitalization Laboratory Pediatric
Maternity/
Newborn
Mental Health/
Substance
Abuse
Rehabilitative/
Devices
Preventive/
Wellness Prescription
Plan
Deductible
Copay (if
applicabl
e)
Coinsuranc
e (if
applicable)
Copay (if
applicabl
e)
Coinsura
nce (if
applicabl
e)
Copay (if
applicabl
e)

Current Essential Benefits Annual Limits (Annual Limit for Each Essential Benefit)
Office Visit
Copays/Coinsurance
Hospital Inpatient
Copay/Coinsurance
Emergen
Copay/Co
Health
Benefit Fund
Health Benefit
Fund
According to the Paperwork
information collection is 0938
search existing data resource
improving this form, please w

None None None

None None None None

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Annual
Limit Waiver
Request
Applicant
Name
Policy Name
(use a new
row for each
policy
application)
Service
Employees
32BJ North
Service
Employees
32BJ North
Coinsura
nce (if
applicabl
e)
Copay (if
applicabl
e)
Coinsuran
ce (if
applicable)
Individual/ Employee
Tier*
Employee
contribution
(if applicable)
Employer
contribution
(if applicable) Total
Employee
contribution
(if applicable)
Employer
contribution
Employee
contribution
(if applicable)
Employer
contribution
Projected Rate Increase
that would result from
compliance with $750,000
Annual Limit Restriction
(in dollars)(Average
Premium by Individual)
(Difference of Column AT
and AQ divided by
Column AQ)
Decrease in
Access to
Benefits that
would result
from
compliance
with $750,000
Annual Limit
Restriction
(describe
briefly in cell
or in a
Plan
Administr
ator/ CEO
of Health
Insuranc
e Issuer
Name

Board of
Trustees
Service
Employee
s BJ North
Health
Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:
Rx
Copay/Coninsurance
Renewal Monthly Premium Rates or
Premium Equivalent Rates if Waiver Granted
(in dollars)*
Projected Rate Increase that would result
from compliance with $750,000 Annual Limit
Restriction (in dollars) (Average Premium
by Individual)*
cy Room
insurance
Health
Benefit Fund
Health Benefit
Fund
None

See
Attachment
Benefit
Fund

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (if
premiums 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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Annual
Limit Waiver
Request
Applicant
Name
Policy Name
(use a new
row for each
policy
application)
Service
Employees
32BJ North
Service
Employees
32BJ North
Title of Individual
Providing
Attestation
Kyle Bragg, Chairman
Eugene Reisman,
Health
Benefit Fund
Health Benefit
Fund
Secretary
Board of Trustees
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Waiver of Annual Limits Requirements
Attachment to Application
Column AR and AT - Projected Rate Increase that would result from compliance
with the $750,000 Annual Limit Restriction
The Service Employees 32BJ North Health Benefit Fund ("Fund") is a
multiemployer Taft-Hartley health and welfare fund. All medical benefits under the
Fund are self insured and funded solely by contributions by contributing employers
pursuant to collective bargaining agreements between the participating employers and
Service Employees International Union 32 BJ. These collective bargaining agreements
have staggered expiration dates ranging from December 2010 through April 2013
although the collective bargaining agreements covering approximately percent of the
Fund's participants expire between March 2011 and April 2013. Since the Employer
contribution rates that fund the Fund are fixed under the collective bargaining
agreements, the Fund cannot at this point determine how it would cover the additional
costs of complying with the annual limits prohibition if the waiver is not granted and if
employer contribution increases cannot be obtained.
Nevertheless, for the purposes of completing this spreadsheet, the Fund has
calculated how much the amount of the employees monthly contributions would
increase, if the costs were paid in that way. As the chart indicates employee
contributions would increase substantially from $ annually to $ annually.
Column AV - Decrease in Access to Benefits that would Result from compliance
with $750,000 Annual Limit Restriction
As a multiemployer Taft Hartley Plan with contribution rates set in collective
bargaining agreements, the Board of Trustees is limited in its ability to fund the costs of
the annual limits required under PPACA. As the Trustees believe that a waiver of the
PPACA annual limits is warranted, no decisions have been made at this time regarding
the actual benefit decreases that would be needed to offset a $750,000 annual limit if
employer contribution increases cannot be obtained. However the Fund's benefit
consultant has determined that overall total Fund assets are expected to decrease by $
by the end of 2011 after accounting for the cost of complying with the applicable
provisions of PPACA. If the Fund is not granted a waiver from the $750,000 annual limit
requirement, and current contributions and the rest of the plan of benefits remain the
same, there would be a percent funding shortfall in 2011. Given this projected
funding shortfall, the Trustees would likely have to consider increases to deductibles
and/or increases to the co-insurance amounts required to be paid by participants if
employer contribution increases cannot be obtained.
Given the compressed time period within which the Plan was required to complete and
submit the waiver application spreadsheet, the Plan's does not have examples of the
benefit reductions or participant cost-sharing increases that would be required if the
Ex. 4
Ex.
4
Ex. 4
Ex. 4
Ex. 4
Ex. 4
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waiver is not granted and if employer contribution increases cannot be obtained. Please
let us know if you need specific calculations.
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file:///T|/...orth%20Health%20Benefit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Completion%2012.23.10.htm[08/12/2011 2:10:41 PM]
From: Andrews, Jane (HHS/OCIIO)
Sent: Thursday, December 23, 2010 8:21 AM
To: 'Gabriele Schroeder'
Cc: Habit, Sandra (HHS/OCIIO); 'Susan Cowell'; 'Howard M. Bard'
Thank you. Your application is complete.

Jane W. Andrews
OCIIO
7501 Wisconsin Ave
Bethesda, MD 20814
301-492-4122 (desk)

From: Gabriele Schroeder [mailto:gschroeder@32BJ FUNDS.COM]
Sent: Tuesday, December 21, 2010 3:15 PM
Cc: Habit, Sandra (HHS/OCIIO); Susan Cowell; 'Howard M. Bard'

On behalf of the trustees of the Service Employees 32BJ North Health Benefit Fund and Susan Cowell, please note the
following:

I. Completed spreadsheet is attached.
II. Please see our answers below:

Thank you,

Gabriele Schroeder
Executive Assistant to Susan Cowell, Executive Director
New York, NY 10013

Tel: (212) 388-3534
Fax: (212)388-2185

From: Andrews, J ane (HHS/OCIIO) [mailto:J ane.Andrews@hhs.gov]


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file:///T|/...orth%20Health%20Benefit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Completion%2012.23.10.htm[08/12/2011 2:10:41 PM]


grandfathering provisions, pursuant to 45 CFR 147.140? YES

collective bargaining agreement will expire. YES, This is a multiemployer plan. Please see the attachment for
information regarding the staggered expiration dates of the collective bargaining agreements.

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

please submit that with the spreadsheet as a separate attachment. Attestation was submitted with application.
We have attached a copy to this e-mail.



Jane W. Andrews
OCIIO
7501 Wisconsin Ave
Bethesda, MD 20814
301-492-4122 (desk)


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file:///T|/...0North%20Health%20Benefit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Approval%2012.29.10.htm[08/12/2011 2:10:42 PM]
From: Botwinick, Alexandra (HHS/OCIIO)
To: scowell@32BJFUNDS.COM
Subject: Service Employees 32BJ North Health Benefit Fund Waiver of the Annual Limits Requirements 12-29-2010
Importance: High
Flag Status: Green
Attachments: Updated Jan 1 Approval Letter .pdf
Good Afternoon,

Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act
Section 2711 for Service Employees 32BJ North Health Benefit Fund. HHS has reviewed your application and
made its determination. Please see the attached letter.

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

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

Sincerely,

Alexandra Botwinick

Office of Oversight
HHS/OCIIO
alexandra.botwinick@hhs.gov

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file:///T|/...rth%20Health%20Benefit%20Plan/Service%20Employees%2032BJ%20-%20FOIA%20Working/Confirmation%2012.30.10.htm[08/12/2011 2:10:43 PM]
From: Gabriele Schroeder [gschroeder@32BJFUNDS.COM] on behalf of Susan Cowell
[scowell@32BJFUNDS.COM]
Sent: Thursday, December 30, 2010 10:25 AM
To: Botwinick, Alexandra (HHS/OCIIO)
Subject: RE: Service Employees 32BJ North Health Benefit Fund Waiver of the Annual Limits Requirements 12-29-
2010
Flag Status: Red
Please be advised that Susan Cowell, Executive Director, has received the email below and determination letter.

Thank you,

Gabriele Schroeder
Executive Assistant to Susan Cowell
New York, NY 10013

Tel: (212) 388-3534
Fax: (212)388-2185

From: Botwinick, Alexandra (HHS/OCIIO) [mailto:Alexandra.Botwinick@hhs.gov]
To: Susan Cowell
Subject: Service Employees 32BJ North Health Benefit Fund Waiver of the Annual Limits Requirements 12-29-2010
Importance: High

Good Afternoon,

Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act
Section 2711 for Service Employees 32BJ North Health Benefit Fund. HHS has reviewed your application and
made its determination. Please see the attached letter.

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

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

Sincerely,

Alexandra Botwinick

Office of Oversight
HHS/OCIIO
alexandra.botwinick@hhs.gov

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Pages 21 through 134 redacted for the following reasons:
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
Exemption 4
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file:///T|/...es%2032BJ %20North%20Health%20Benefit%20Plan/Service%20Employees%2032BJ %20-%20FOIA%20Working/Waiver.

htm[08/12/2011 2:10:39 PM]

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