Southeast Laborers - Redacted Bates HW

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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Pages 5 through 6 redacted for the following reasons: ---------------------------Exemption 4
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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
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
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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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
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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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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%
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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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Plan Administrator
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Donny Dowlen
Plan Administrator
Donny Dowlen
Plan Administrator
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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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12/31/2011
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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.
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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
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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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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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.
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
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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
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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
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:
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
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SE Laborers:000021
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.
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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.

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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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
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
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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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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
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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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
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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.
SE Laborers:000028
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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
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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
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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
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SE Laborers:000031
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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
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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Southeast Laborers - Redacted Bates HW

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Southeast Laborers - Redacted Bates HW

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From: Donny Dowlen [donny.dowlen@southernbenefit.

Document obtained by CompleteColorado.com

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

Document obtained by CompleteColorado.com

Document obtained by CompleteColorado.com

Document obtained by CompleteColorado.com

Document obtained by CompleteColorado.com

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

Document obtained by CompleteColorado.com

Zip Code 20201 20202 20201 20202

Washington Washington Washington Washington

Document obtained by CompleteColorado.com

Ambulatory None None None None

donny.dowlen @southernbe nefit.com Limited Benefit

Document obtained by CompleteColorado.com

Hospitalization None None None None

Laboratory None None None None

Mental Health/ Substance Abuse None None

Rehabilitative/ Devices None None None None

Document obtained by CompleteColorado.com

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

Document obtained by CompleteColorado.com

Employee contribution $100.00 $150.00 $150.00 $150.00

Employer contribution $600.00 $700.00 $800.00

Employer contribution $650.00 $750.00 $850.00

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

Document obtained by CompleteColorado.com

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

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

Plan Administr ator/ CEO of Health Insurance Issuer Name

Title of Individual Providing Attestation

Document obtained by CompleteColorado.com

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

If Yes TaftHartley then Date Collective Bargaining Agreement Expires

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

Document obtained by CompleteColorado.com

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

Document obtained by CompleteColorado.com

II. In addition, please provide the following information:

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

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

Document obtained by CompleteColorado.com

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

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

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

Document obtained by CompleteColorado.com

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

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

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

II. In addition, please provide the following information:

Southern Benefit Administrators 800-831-4914

Document obtained by CompleteColorado.com

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

Document obtained by CompleteColorado.com

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

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

II. In addition, please provide the following information:

Confirm whether your plan provides any lifetime limits.

Yes and yes as noted in our initial submission

Yes, as noted in our initial submission. - $

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 by CompleteColorado.com