et eC

Ex. 4

ol o
Ex. 4 Ex. 4

Co m

pl

ra do .
UlsterGreene:000001

co m

Co m pl et eC ol o ra do . co m

UlsterGreene:000002

Pages 3 through 14 redacted for the following reasons: ---------------------------Exemption 4

Co m

pl

et eC

ol o
UlsterGreene:000003

ra do .

co m

From: Sheer, Jennifer (HHS/OCIIO) Sent: Monday, December 20, 2010 2:53 PM To: 'johnmc@ugarc.org' Subject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application Attachments: Waiver Application Form.xls Follow Up Flag: Follow up Flag Status: Completed

----------------------------------

Jennifer L. O. Sheer

Office of Consumer Support Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services jennifer.sheer@hhs.gov 301-492-4487

Co m

Dear Applicant: Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. In order to expedite your application, please provide the following information: I. Please complete the entire annual limits spreadsheet, attached to this email. 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 the plan was created pursuant to the Taft-Hartley Act. If yes: o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008. o Please provide the date for which the Collective Bargaining Agreement will expire. In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once this information is received and the application is complete, it will be processed by the Department of Health and Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision. Thank you.

pl

et eC

ol o

ra do .

file:///T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2020%202010.htm[07/20/2011 3:40:20 PM]

co m

UlsterGreene:000004

Co m

Mission: " To offer people with intellectual and other developmental disabilities opportunities to live and experience full lives".
To donate to Ulster-Greene ARC Foundation, click on the donate button below. Thank you for your support .

pl

Chief Financial Officer Ulster-Greene ARC 471 Albany Avenue Kingston, NY 12401 Phone: (845) 331-4300 Ext. 256 Fax: (845) 331-4931 Email: johnmc@ugarc.org

et eC

From: Sheer, Jennifer (HHS/OCIIO) [mailto:Jennifer.Sheer@hhs.gov] Sent: Monday, December 20, 2010 2:53 PM To: John McHugh Subject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application

UlsterGreene:000005

file:///T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2021%202010.htm[07/20/2011 3:40:21 PM]

ol o

John McHugh

ra do .

From: John McHugh [johnmc@ugarc.org] Sent: Tuesday, December 21, 2010 4:01 PM To: Sheer, Jennifer (HHS/OCIIO) Cc: Mark Vanyo Subject: RE: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application Attachments: Copy of Waiver Application Form (Final)UGARC.xls Follow Up Flag: Follow up Flag Status: Completed Dear Ms. Sheer: In regards to our application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act). Please find attached the completed annual limits spreadsheet. In addition, please find the information requested in Part II answered in red. If you have any questions or need any additional information, please do not hesitate to contact me. Thank you. John

co m

 ----------------------------------

Jennifer L. O. Sheer

NOTICE OF PRIVILEGE and CONFIDENTIALITY The information contained in this electronic mail is privileged and confidential intended solely for the addressee. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or reproduction of this electronic mail is strictly prohibited. If you have received this electronic mail in error, please contact Ulster-Greene ARC at 845-331-4300 ext.275 and delete and destroy the original electronic mail and all copies. Thank you.

Co m

Office of Consumer Support Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services jennifer.sheer@hhs.gov 301-492-4487

pl

et eC

Dear Applicant: Thank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act) Section 2711. In order to expedite your application, please provide the following information: I. Please complete the entire annual limits spreadsheet, attached to this email. 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? Yes, the plan was in existence prior to March 23, 2010. No, we are NOT grandfathering the plan for purposes of this waiver. Confirm whether the plan was created pursuant to the Taft-Hartley Act. If yes:No, the plan was NOT created pursuant to the Taft-Hartley Act. o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008. N/A o Please provide the date for which the Collective Bargaining Agreement will expire. N/A In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once this information is received and the application is complete, it will be processed by the Department of Health and Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision. Thank you.

ol o

ra do .

file:///T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2021%202010.htm[07/20/2011 3:40:21 PM]

co m

UlsterGreene:000006

ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name Applicant ABC

Policy Name (use a new row for each Applicant policy (Plan/ Policy application) Situs) City Plan 1 Washington

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

Street Address 100 ABC Drive

City Washington

State DC

Phone Number (including Email Zip Code area code) Address 1-800-ABC- abc@abchea 20201 1234 lthplan.com Limited Benefit

ra do .c om

Total Number of Individuals Type of Covered by Current Coverage Policy Plan Overall (e.g., Limited SelfIndividual or (include all Annual Benefit, HRA, Insured Group dependents Limit (in Rx only, Other) (Yes/No) Policy covered) dollars) Yes Group 4,000 $100,000

Ambulatory None

Emergency None
Ex. 4

Ulster Greene ARC

Standalone HRA

Kingston

NY

01/01/2011

John McHugh

471 Albany Ave

Kingston

NY

12401

ol o
1-845-3314300 johnm@ugar c.org

HRA

Yes

Group

PRA Disclosure Statement

Co m

pl

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

et eC

UlsterGreene:000007

ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name Applicant ABC

Policy Name (use a new row for each policy application) Plan 1

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

Preventive/ Wellness

ra do .c om
Prescription

Current Essential Benefits Annual Limits (Annual Limit for Each Essential Benefit)

Office Visit Hospital Inpatient Emergency Room Rx Copays/Coinsurance Copay/Coinsurance Copay/Coinsurance Copay/Coninsurance

Coinsura Coinsura Copay (if Coinsuranc Copay (if nce (if Copay (if nce (if Copay (if Coinsuran Plan applicabl e (if applicabl applicabl applicabl applicabl applicabl ce (if Deductible e) applicable) e) e) e) e) e) applicable)

Ex. 4

Ulster Greene ARC

Standalone HRA

PRA Disclosure Statement According to the Paperwork information collection is 0938 search existing data resource improving this form, please w

Co m

pl

et eC

ol o

UlsterGreene:000008

ANNUAL LIMIT WAIVER APPLICATION 2010

ra do .c om

Current Monthly Premium Rates or Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted (in dollars)*

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Restriction (in dollars) (Average Premium by Individual)*

Annual Limit Waiver Request Applicant Name Applicant ABC

Policy Name (use a new Employee Employer row for each Individual/ Employee contribution contribution policy application) Tier* (if applicable) (if applicable) Plan 1 Employee $100.00 $600.00

Total $700.00

Employee Employer contribution contribution (if applicable) (if applicable) $110.00 $650.00

Total $760.00

Employee Employer contribution contribution (if applicable) (if applicable) $125.00 $800.00

Total

Decrease in Access to Benefits that Projected Rate Increase would result that would result from from compliance with $750,000 compliance Annual Limit Restriction with $750,000 (in dollars)(Average Annual Limit Premium by Individual) Restriction (Difference of Column AT (describe and AQ divided by briefly in cell Column AQ) or in a 21.71%
Ex. 4

Plan Administr ator/ CEO of Health Insuranc e Issuer Name Jane Doe

Title of Individual Providing Attestation Plan Administrator

$925.00

None

ol o

Ulster Greene ARC

Standalone HRA

Employee + Family

eliminate (or significantly reduce) benefit

Laurie Kelley

Plan Administrator

PRA Disclosure Statement According to the Paperwork information collection is 0938 search existing data resource improving this form, please w

Co m

pl

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (if premiums are a range based on years of service or age) and by tier (Employee, Employee + Spouse, Employee + Child, Family, etc.) as applicable. If you are an issuer, please provide the premium amount in the column titled, "Total" (Column AN, AQ and AT).

et eC

UlsterGreene:000009

From: Sheer, Jennifer (HHS/OCIIO) Sent: Thursday, December 23, 2010 11:41 AM To: 'John McHugh' Subject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application Follow Up Flag: Follow up Flag Status: Completed

----------------------------------

Jennifer L. O. Sheer
Office of Consumer Support Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services jennifer.sheer@hhs.gov 301-492-4487

Co m

pl

et eC

ol o
UlsterGreene:000010

file:///T|/...ster%20Greene%20ARC%20Standalone%20HRA%20Annual%20Limit%20Waiver%20Application%20Dec%2023%202010.htm[07/20/2011 3:40:21 PM]

ra do .

co m

Dear Applicant: Thank you for your information. Your application is now complete and you should receive a determination of your application within 30 days. Thank you.

From: Habit, Sandra (HHS/OCIIO) Sent: Thursday, December 30, 2010 6:00 PM To: 'johnmc@ugarc.org' Subject: Ulster Greene ARC Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Afternoon, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Ulster Greene ARC.HHS has reviewed your application and made its determination. Please see the attached letter. Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance. Sincerely,
Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@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 disclosures may result in prosecution to the full extent of the law.

Co m

pl

et eC

ol o
UlsterGreene:000011

file:///T|/...RC%20Approval%20Letter%20for%20a%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-30-2010.htm[07/20/2011 3:40:22 PM]

ra do .

co m

From: Botwinick, Alexandra (HHS/OCIIO) Sent: Wednesday, January 12, 2011 11:32 AM To: 'johnm@ugarc.org' Cc: Habit, Sandra (HHS/OCIIO) Subject: Ulster Greene ARC Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Ulster Greene ARC. HHS has reviewed your application and made its determination. Please see the attached letter. Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance. Sincerely,

et eC pl

Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

Co m

ol o

UlsterGreene:000012

file:///T|/...W/Applications%20with%20NO%2012600%20Response%20[YELLOW]/Ulster%20Greene%20ARC/Approval%201.12.11.htm[07/20/2011 3:40:22 PM]

ra do .

co m

Co m pl et eC ol o ra do . co m

UlsterGreene:000013

Co m pl et eC ol o ra do . co m

UlsterGreene:000014