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From: Donny Dowlen [donny.dowlen@southernbenefit.

com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver Attachments: 13115.pdf
Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen Southern Benefit Administrators 800-831-4914

Document obtained by CompleteColorado.com

Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com , and delete the original message. Your cooperation is appreciated.

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SE Laborers:000001

file:///T|/...Applications%20with%20NO%2012600%20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Waiver.htm[08/11/2011 10:58:29 AM]

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Document obtained by CompleteColorado.com

Ex. 4

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Ex. 4 Ex. 4 Ex. 4 Ex. 4 Ex. 4 Ex. 4 Ex. 4

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SE Laborers:000002

Document obtained by CompleteColorado.com

Ex. 4 Ex. 4

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SE Laborers:000003

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Document obtained by CompleteColorado.com

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SE Laborers:000004

Ex. 4

Document obtained by CompleteColorado.com

Pages 5 through 6 redacted for the following reasons: ---------------------------Exemption 4

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Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Name Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund

Policy Name (use a new row for each Applicant policy (Plan/ Policy application) Situs) City Silver Plan Silver Plan Silver Plan Silver Plan Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Washington Washington Washington Washington

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) State (mm/dd/yyyy) Name DC DC DC DC 01/01/2011 01/01/2011 01/01/2011 01/01/2011

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Street Address City Jane Doe Jane Doe Jane Doe Jane Doe Donny Dowlen 100 ABC Drive 100 ABC Drive 100 ABC Drive 100 ABC Drive 2001 Caldwell Drive 2001 Caldwell Drive 2001 Caldwell Drive 2001 Caldwell Drive Donny Dowlen Donny Dowlen Donny Dowlen

State DC DC DC DC

Zip Code 20201 20202 20201 20202

Washington Washington Washington Washington

Goodlettsville

TN

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04/01/2011

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Goodlettsville

TN

37072

Goodlettsville

TN

04/01/2011

Goodlettsville

TN

37072

Goodlettsville

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TN

04/01/2011

Goodlettsville

TN

37072

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Goodlettsville

TN

04/01/2011

Goodlettsville

TN

37072

SE Laborers:000006

Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Name Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund

Phone Number (including area code) (xxx-xxxxxx) 1-800-ABC1234 1-800-ABC1234 1-800-ABC1234 1-800-ABC1234 1-800-8314914 1-800-8314914

Email Address abc@abcheal thplan.com abc@abcheal thplan.com abc@abcheal thplan.com abc@abcheal thplan.com

Type of Coverage (e.g., Limited Benefit, HRA, SelfRx only, Other) Insured Limited Benefit Limited Benefit Limited Benefit Limited Benefit Yes Yes Yes Yes

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Group Group Group Group 4,000 2,500 4,000 2,500 $100,000 $100,000 $100,000 $100,000 Group Group Group Group

Total Number of Individuals Covered by Policy (include all Current Plan Individual or dependents Annual Limit (in dollars) Group Policy covered)

Ambulatory None None None None


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Yes

donny.dowlen @southernbe nefit.com Limited Benefit donny.dowlen @southernbe nefit.com Limited Benefit donny.dowlen @southernbe nefit.com Limited Benefit

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none

Yes

none

1-800-8314914

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Yes

none

1-800-8314914

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donny.dowlen @southernbe nefit.com Limited Benefit

Yes

none

SE Laborers:000007

Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Name Emergency Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund $5,000 $5,000 $5,000 $5,000

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Maternity/ Newborn None None None None None None None None none none none none none none none none

Hospitalization None None None None

Laboratory None None None None

Pediatric

Mental Health/ Substance Abuse None None

Rehabilitative/ Devices None None None None

None

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none

none

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none

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SE Laborers:000008

Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Preventive/ Name Wellness Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund None None None None

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50.00% 50.00% 50.00% 50.00% $100.00 $100.00 $100.00 $100.00 50.00% 50.00% 50.00% 50.00%

Prescription $3,000.00 $3,000.00 $3,000.00 $3,000.00

Coinsura Copay (if Copay (if Coinsuranc Copay (if nce (if Plan applicable e (if applicable applicable applicable ) ) Deductible ) applicable) ) $500.00 $500.00 $500.00 $500.00 $15.00 $15.00 $15.00 $15.00 $100.00 $100.00 $100.00 $100.00

Coinsura nce (if Copay (if applicable applicable ) ) 50.00% 50.00% 50.00% 50.00% $10.00 $10.00 $10.00 $10.00
Ex. 4

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SE Laborers:000009

Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Coinsurance Name (if applicable) Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund None None None None

Individual/ Employee Tier* Employee Employee + Child Employee + Spouse Employee + Family

Employee contribution $100.00 $150.00 $150.00 $150.00

Employer contribution $600.00 $700.00 $800.00

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Total Employee contribution $110.00 $700.00 $850.00 $150.00 $950.00 $150.00 $1,250.00 $150.00

Employer contribution $650.00 $750.00 $850.00

Total $760.00 $900.00 $1,000.00 $1,300.00


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$1,100.00

$1,150.00

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SE Laborers:000010

Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Employee Name contribution Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund $250.00 $250.00 $250.00 $250.00

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38.16% 27.78% 22.50% 26.92%
Ex. 4

Employer contribution $800.00 $900.00 $975.00 $1,400.00

Total $1,050.00 $1,150.00 $1,225.00 $1,650.00

Decrease in Access to Benefits that would result Projected Rate Increase from that would result from compliance with $750,000 compliance Annual Limit Restriction (in with $750,000 dollars)(Average Premium Annual Limit by Individual) (Difference Restriction (describe of Column AV and AS briefly) divided by Column AS) Termination of the plan Termination of the plan Termination of the plan Termination of the plan

Plan Administr ator/ CEO of Health Insurance Issuer Name

Title of Individual Providing Attestation

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Plan Jane Doe Administrator Plan Jane Doe Administrator Plan Jane Doe Administrator Plan Jane Doe Administrator Donny Dowlen Plan Administrator

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forced to eliminate the non essential trustees will be forced to eliminate the non essential trustees will be forced to eliminate the non essential trustees will be forced to eliminate the non essential benefits and

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Donny Dowlen

Plan Administrator

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Donny Dowlen

Plan Administrator

Donny Dowlen

Plan Administrator

SE Laborers:000011

Document obtained by CompleteColorado.com

Annual Limit Waiver Request Applicant Taft-Hartley Name Plan Applicant ABC Applicant ABC Applicant ABC Applicant ABC Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Southeast Laborers Health Fund Yes Yes Yes Yes

Compliance with Grandfather Regulation Yes Yes Yes Yes

Lead Reviewer E. Pham E. Pham E. Pham E. Pham

01/01/2013 01/01/2013 01/01/2013 01/01/2013

yes

12/31/2011

yes

12/31/2011

yes

12/31/2011

yes

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yes yes

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yes yes

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Date of Receipt 09/01/2010 09/01/2010 09/01/2010 09/01/2010
SE Laborers:000012

If Yes TaftHartley then Date Collective Bargaining Agreement Expires

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.

From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver

Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen Southern Benefit Administrators 800-831-4914

Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it
SE Laborers:000013

file:///T|/...%2012600%20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20info%201.31.11.htm[08/11/2011 10:58:30 AM]

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From: Moultrie, Cam (HHS/OCIIO) Sent: Monday, January 31, 2011 12:39 PM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Southeast Laborers Health Fund Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Please provide the following information: I. Please complete the entire annual limits spreadsheet 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, 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 your plan provides any lifetime limits. Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and expiration dates of the collective bargaining agreement. In order to complete your application, please provide this information by 5:00 pm, February 3, 2011. 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.

Document obtained by CompleteColorado.com

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Document obtained by CompleteColorado.com has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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SE Laborers:000014

file:///T|/...%2012600%20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20info%201.31.11.htm[08/11/2011 10:58:30 AM]

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From: Donny Dowlen [donny.dowlen@southernbenefit.com] Sent: Tuesday, February 01, 2011 3:13 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund Attachments: 21116.xls

Document obtained by CompleteColorado.com

Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Please provide the following information:

II. In addition, please provide the following information:

Yes and yes as noted in our initial submission Confirm whether your plan provides any lifetime limits. Yes, as noted in our initial submission. - $
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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?

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Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and expiration dates of the collective bargaining agreement. Yes with expiration date of 12/31/2011 as noted in our initial submission In order to complete your application, please provide this information by 5:00 pm, February 3, 2011. 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.
SE Laborers:000015

file:///T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20info%20response%202.1.11.htm[08/11/2011 10:58:31 AM]

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I. Please complete the entire annual limits spreadsheet 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.

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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, January 31, 2011 11:39 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Southeast Laborers Health Fund

maximum lifetime

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Enclosed is the completed spreadsheet. Note that there is only one tier of employees covered as all employees pay the same amount for their coverage. It is therefore not necessary that we keep coverage by employee, employee/child, employee/family, etc. An employee who is single pays the same as the employee with a wife and 3 children. Its the way these types of union funds typically operate. There are no separate rates. We have responded to your questions below. Let us know if you need anything else. Donny Dowlen

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Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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Document obtained by CompleteColorado.com Thank you. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen Southern Benefit Administrators 800-831-4914

file:///T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20info%20response%202.1.11.htm[08/11/2011 10:58:31 AM]

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SE Laborers:000016

From: Moultrie, Cam (HHS/OCIIO) Sent: Wednesday, February 02, 2011 10:04 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund Pursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Please confirm whether this lifetime limit will be eliminated from your plan. Thank you.

Document obtained by CompleteColorado.com

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.

From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Tuesday, February 01, 2011 3:13 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund

I. Please complete the entire annual limits spreadsheet 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, please provide the following information:
SE Laborers:000017

file:///T|/...ponse%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Question%20regarding%20lifetime%20limit%202.2.11.htm[08/11/2011 10:58:31 AM]

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Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Please provide the following information:

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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, January 31, 2011 11:39 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Southeast Laborers Health Fund

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Enclosed is the completed spreadsheet. Note that there is only one tier of employees covered as all employees pay the same amount for their coverage. It is therefore not necessary that we keep coverage by employee, employee/child, employee/family, etc. An employee who is single pays the same as the employee with a wife and 3 children. Its the way these types of union funds typically operate. There are no separate rates. We have responded to your questions below. Let us know if you need anything else. Donny Dowlen

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Document obtained CompleteColorado.com Confirm whether the plan was in existence prior to by March 23, 2010. If so, is the plan in compliance with grandfathering provisions, pursuant to 45 CFR 147.140?

Yes and yes as noted in our initial submission Confirm whether your plan provides any lifetime limits. Yes, as noted in our initial submission. - $
Ex. 4

maximum lifetime

Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and expiration dates of the collective bargaining agreement. Yes with expiration date of 12/31/2011 as noted in our initial submission In order to complete your application, please provide this information by 5:00 pm, February 3, 2011. 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. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen Southern Benefit Administrators 800-831-4914 Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.
Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged
SE Laborers:000018

file:///T|/...ponse%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Question%20regarding%20lifetime%20limit%202.2.11.htm[08/11/2011 10:58:31 AM]

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obtained by CompleteColorado.com information of Southern Benefit Administrators, Inc. Document Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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SE Laborers:000019

file:///T|/...ponse%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Question%20regarding%20lifetime%20limit%202.2.11.htm[08/11/2011 10:58:31 AM]

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From: Donny Dowlen [donny.dowlen@southernbenefit.com] Sent: Wednesday, February 02, 2011 3:23 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell' Subject: RE: Waiver Application for Southeast Laborers Health Fund

Document obtained by CompleteColorado.com

Cam, thank you for the email. As you know, the lifetime limit must be removed beginning of the plan year on or after September 23, 2010. For this plan, the after September 23, 2010 is April 1, 2011. The lifetime limit will be removed and the trustees intend to maintain the plans grandfather status. Let me know anything thing else regarding this application. Thank you. Donny Dowlen From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Wednesday, February 02, 2011 9:04 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund

before the first plan year by April 1, 2011 if you need

Pursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Please confirm whether this lifetime limit will be eliminated from your plan. Thank you. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Tuesday, February 01, 2011 3:13 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund Enclosed is the completed spreadsheet. Note that there is only one tier of employees covered as all employees pay the same amount for their coverage. It is therefore not necessary that we keep coverage by employee, employee/child, employee/family, etc. An employee who is single pays the same as the employee with a wife and 3 children. Its the way these types of union funds typically operate. There are no separate rates. We have responded to your questions below. Let us know if you need anything else. Donny Dowlen From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, January 31, 2011 11:39 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Southeast Laborers Health Fund
SE Laborers:000020

file:///T|/...ELLOW]/Southeast%20Laborers%20Health%20Fund/Question%20regarding%20lifetime%20limit%20response%202.2.11.htm[08/11/2011 10:58:31 AM]

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Document obtained by CompleteColorado.com Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Please provide the following information:

I. Please complete the entire annual limits spreadsheet 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.

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? Yes and yes as noted in our initial submission Confirm whether your plan provides any lifetime limits. Yes, as noted in our initial submission. - $
Ex. 4

Yes with expiration date of 12/31/2011 as noted in our initial submission In order to complete your application, please provide this information by 5:00 pm, February 3, 2011. 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. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen

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Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and expiration dates of the collective bargaining agreement.

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maximum lifetime

file:///T|/...ELLOW]/Southeast%20Laborers%20Health%20Fund/Question%20regarding%20lifetime%20limit%20response%202.2.11.htm[08/11/2011 10:58:31 AM]

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II. In addition, please provide the following information:

SE Laborers:000021

Southern Benefit Administrators 800-831-4914

Document obtained by CompleteColorado.com

Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated. Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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file:///T|/...ELLOW]/Southeast%20Laborers%20Health%20Fund/Question%20regarding%20lifetime%20limit%20response%202.2.11.htm[08/11/2011 10:58:31 AM]

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SE Laborers:000022

From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, February 03, 2011 11:55 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell' Subject: RE: Waiver Application for Southeast Laborers Health Fund
Please breakdown the number of employees in each employee tier.

Document obtained by CompleteColorado.com

From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Wednesday, February 02, 2011 3:23 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell' Subject: RE: Waiver Application for Southeast Laborers Health Fund

Pursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Please confirm whether this lifetime limit will be eliminated from your plan. Thank you. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Tuesday, February 01, 2011 3:13 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund

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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Wednesday, February 02, 2011 9:04 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund

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Cam, thank you for the email. As you know, the lifetime limit must be removed beginning of the plan year on or after September 23, 2010. For this plan, the after September 23, 2010 is April 1, 2011. The lifetime limit will be removed and the trustees intend to maintain the plans grandfather status. Let me know anything thing else regarding this application. Thank you. Donny Dowlen

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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.

before the first plan year by April 1, 2011 if you need

SE Laborers:000023

file:///T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%202.3.11.htm[08/11/2011 10:58:32 AM]

Document obtained CompleteColorado.com Enclosed is the completed spreadsheet. Note that there is by only one tier of employees covered as all employees pay the same amount for their coverage. It is therefore not necessary that we keep coverage by employee, employee/child, employee/family, etc. An employee who is single pays the same as the employee with a wife and 3 children. Its the way these types of union funds typically operate. There are no separate rates. We have responded to your questions below. Let us know if you need anything else. Donny Dowlen

I. Please complete the entire annual limits spreadsheet 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, 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 your plan provides any lifetime limits.

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Yes and yes as noted in our initial submission

Yes, as noted in our initial submission. - $

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Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and expiration dates of the collective bargaining agreement. Yes with expiration date of 12/31/2011 as noted in our initial submission In order to complete your application, please provide this information by 5:00 pm, February 3, 2011. 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.
SE Laborers:000024

file:///T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%202.3.11.htm[08/11/2011 10:58:32 AM]

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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, January 31, 2011 11:39 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Southeast Laborers Health Fund Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Please provide the following information:

maximum lifetime

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Document obtained by CompleteColorado.com

Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

Co m

pl

Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

ra do .

file:///T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%202.3.11.htm[08/11/2011 10:58:32 AM]

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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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen Southern Benefit Administrators 800-831-4914

SE Laborers:000025

From: Donny Dowlen [donny.dowlen@southernbenefit.com] Sent: Thursday, February 03, 2011 12:24 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund

Document obtained by CompleteColorado.com

Cam, please note my response to you on 2/1/11. There is only one tier of employees since they all pay the same regardless of how many are covered in the family. Its the typical way Taft Hartley union plans work. It is not necessary for us to keep records broken down by tier and this is not something we have. Please let me know if you need anything else. Donny Dowlen From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, February 03, 2011 10:55 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell' Subject: RE: Waiver Application for Southeast Laborers Health Fund

From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Wednesday, February 02, 2011 9:04 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund Pursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 2010, except in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously had a lifetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of the plan. Please confirm whether this lifetime limit will be eliminated from your plan. Thank you.
SE Laborers:000026

file:///T|/...20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%20response%202.3.11.htm[08/11/2011 10:58:32 AM]

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Please breakdown the number of employees in each employee tier. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Wednesday, February 02, 2011 3:23 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell' Subject: RE: Waiver Application for Southeast Laborers Health Fund Cam, thank you for the email. As you know, the lifetime limit must be removed before the beginning of the plan year on or after September 23, 2010. For this plan, the first plan year after September 23, 2010 is April 1, 2011. The lifetime limit will be removed by April 1, 2011 and the trustees intend to maintain the plans grandfather status. Let me know if you need anything thing else regarding this application. Thank you. Donny Dowlen

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Document obtained by CompleteColorado.com

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? Yes and yes as noted in our initial submission Confirm whether your plan provides any lifetime limits.
SE Laborers:000027

file:///T|/...20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%20response%202.3.11.htm[08/11/2011 10:58:32 AM]

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I. Please complete the entire annual limits spreadsheet 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.

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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, January 31, 2011 11:39 AM To: Donny Dowlen Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Southeast Laborers Health Fund Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. Please provide the following information:

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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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Tuesday, February 01, 2011 3:13 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund Enclosed is the completed spreadsheet. Note that there is only one tier of employees covered as all employees pay the same amount for their coverage. It is therefore not necessary that we keep coverage by employee, employee/child, employee/family, etc. An employee who is single pays the same as the employee with a wife and 3 children. Its the way these types of union funds typically operate. There are no separate rates. We have responded to your questions below. Let us know if you need anything else. Donny Dowlen

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Document obtained by CompleteColorado.com Yes, as noted in our initial submission. -$ maximum lifetime

Ex. 4

Confirm whether the plan was created pursuant to the Taft-Hartley Act and, if applicable, the effective and expiration dates of the collective bargaining agreement. Yes with expiration date of 12/31/2011 as noted in our initial submission In order to complete your application, please provide this information by 5:00 pm, February 3, 2011. 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. 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. From: Donny Dowlen [mailto:donny.dowlen@southernbenefit.com] Sent: Monday, January 03, 2011 4:34 PM To: HHS HealthInsurance (HHS) Subject: Waiver Enclosed is documentation for the Southeast Laborers Health Fund. Donny Dowlen Southern Benefit Administrators 800-831-4914 Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.
SE Laborers:000028

file:///T|/...20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%20response%202.3.11.htm[08/11/2011 10:58:32 AM]

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Document obtained by CompleteColorado.com Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

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SE Laborers:000029

file:///T|/...20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%20response%202.3.11.htm[08/11/2011 10:58:32 AM]

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Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at abuse@southernbenefit.com, and delete the original message. Your cooperation is appreciated.

Co m

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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From: Moultrie, Cam (HHS/OCIIO) Sent: Monday, February 14, 2011 11:18 AM To: 'Donny Dowlen' Subject: Waiver Application for Southeast Laborers Health Fund Attachments: April 1 Approval .pdf Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Southeast Laborers Health Fund. HHS has reviewed your application and made its determination. Please see the attached letter. The attached letter refers to the following plans: Southeast Laborers Health Fund Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance. Cam Lynne Moultrie Division of Oversight Center for Consumer Information and Insurance Oversight U.S. Department of Health & Human Services 301.492.4174 cam.moultrie@hhs.gov

Document obtained by CompleteColorado.com

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file:///T|/...outheast%20Laborers%20Health%20Fund/Waiver%20Application%20for%20Southeast%20Laborers%20Health%20Fund.htm[08/11/2011 10:58:33 AM]

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SE Laborers:000030

Document obtained by CompleteColorado.com

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SE Laborers:000031

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Document obtained by CompleteColorado.com

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SE Laborers:000032

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From: Donny Dowlen [donny.dowlen@southernbenefit.com] Sent: Monday, February 14, 2011 3:39 PM To: Moultrie, Cam (HHS/OCIIO) Subject: RE: Waiver Application for Southeast Laborers Health Fund
Receipt confirmed. From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, February 14, 2011 10:18 AM To: Donny Dowlen Subject: Waiver Application for Southeast Laborers Health Fund

Document obtained by CompleteColorado.com

Southeast Laborers Health Fund

Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance. Cam Lynne Moultrie Division of Oversight Center for Consumer Information and Insurance Oversight U.S. Department of Health & Human Services 301.492.4174 cam.moultrie@hhs.gov 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.
Privacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at
SE Laborers:000033

file:///T|/...st%20Laborers%20Health%20Fund/RE%20Waiver%20Application%20for%20Southeast%20Laborers%20Health%20Fund.htm[08/11/2011 10:58:33 AM]

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Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Southeast Laborers Health Fund. HHS has reviewed your application and made its determination. Please see the attached letter. The attached letter refers to the following plans:

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Document obtained by CompleteColorado.com abuse@southernbenefit.com , and delete the original message. Your cooperation is appreciated.

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SE Laborers:000034

file:///T|/...st%20Laborers%20Health%20Fund/RE%20Waiver%20Application%20for%20Southeast%20Laborers%20Health%20Fund.htm[08/11/2011 10:58:33 AM]

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