From: Danielle T. Norris [dnorris@slevinhart.

com] Sent: Wednesday, December 29, 2010 5:46 PM To: HHS HealthInsurance (HHS); OCIIO Oversight Cc: Sharon M. Goodman; William H. Tobin; Scott.Weltz@Milliman.com Subject: waiver Attachments: 1-334178-Local_400_PPACA_Waiver_Application.pdf; 1-333599Local_400_Waiver_Chart_Explanatory_Memorandum.doc; 1-334289Local_400_Waiver_Application_Chart.xls
Mr. Mayhew:

I. The completedHHS spreadsheetand an explanatory memorandum are attached hereto.

III. The Fund is a Taft-Hartley employee welfare benefit plan. The effective dates and expiration dates of theprincipal collective bargaining agreement covering Ex. % of all participants in the Fund are as follows: 10/14/2007-10/15/2011. 4

Best regards, Danielle Norris Danielle T. Norris Attorney At Law Slevin & Hart, P.C. 1625 Massachusetts Ave., N.W., Suite 450 Washington, D.C. 20036 202-797-8700 Tel 202-234-8231 Fax dnorris@slevinhart.com

Co m

pl

et eC

ol o
UFCW L400:000001

Please feel free to contact me with any questions.

file:////co-adshare/...OI%20Processing%20Team/Mike/United%20Food%20and%20Commercial%20Workers%20Local%20400/waiver.htm[11/15/2011 3:33:46 PM]

ra do .

II. The Fund was in existence prior to March 23, 2010. It is our understanding thatall the Fund's Plans meet the requirements of a "grandfathered plan," as that term is used in applicable regulations. The Plans are prepared to comply with the PPACA requirements applicable to grandfathered plans, effectiveFebruary 1, 2011.

co m

Attached please find an Application for Waiver of the PPACA Lifetime Limits Prohibition, filed on behalf ofthe United Food and Commercial WorkersLocal 400 and Employers Health and Welfare Fund ("Fund"). In addition to the Application, please note the following:

December 16,2010

SENT

BY

E-MAIL
(e-mail: healthinsurance~hhs.gov)

Re:

ol o

Dear Mr. Mayhew:

ra do .

Department of Health and Human Services Office of Consumer Information and Office of Oversight ATTN: James Mayhew, Room 737-F-04 200 Independence Avenue, SW Washington DC 20201

Waiver - Restricted Annual Limits for Fund Year Beginning February 1,2011

co m
400
400 and Employers
UFCW L400:000002

The Board of Trustees of the United Food and Commercial Workers Local

and Employers Health and Welfare Fund (the "Trustees") is the plan sponsor and plan
Health and Welfare Fund (the "Fund"). The Fund is a multiemployer plan with a Plan Year beginning February 1, 2011. The Fund provides health and welfare benefits to

employees and their dependents who are covered by collective bargaining agreements
negotiated by employers contributing to the Fund and United Food and Commercial
Workers Union Local

paid only from these assets. The Fund offers health and welfare benefits to part-time and

full-time employees, retirees and their dependents.

Employer and employee contribution rates are set by collective bargaining agreements negotiated by the Bargaining Parties. Thus, the Trustees administer the Fund and set benefits based on the limited pool of assets available to them. The Trustees have no legal abilty to require any increase in the contributions to the Fund in excess of the rates provided for under the collective bargaining agreements.

The Trustees are required to administer the Fund consistent with their fiduciary duties under the Employee Retirement Income Security Act of 1974 ("ERISA") and the Fund's governing documents. With the help and direction of the Bargaining Parties, the Fund's Trustees have created and administered the Fund's Plan of benefits, in the manner

Co m

Board of Trustees, which consists of both Union and Employer representatives selected by the Union and the Employers which have entered into collective bargaining agreements relating to the Plan. All health benefits under the Fund are self-funded and

pl

et eC

administrator of the United Food and Commercial Workers Local

400 (the "Bargaining Parties"). The Plan is administered by a

Department of Health and Human Services Office of Consumer Information and Office of Oversight ATTN: James Mayhew
December 16,2010
Page 2

confines of the Fund's assets, while limiting the out-of-pocket costs payable by

participants and dependents. ERISA requires that the Trustees take those actions that are
necessary and appropriate pursuant to their fiduciary duties to safeguard the Fund's
contributions wil not occur until the current collective bargaining agreements expire.

This of course limits the Trustees' abilty to fund the costs of the mandated enhanced
benefits required under the Patient Protection and Affordable Care Act ("PPACA").

Further, faced with such dramatic increases in costs, employers also may attempt to negotiate out of the Plan or try to eliminate some coverage altogether. The effect of not

expiring contracts wil lose some access to coverage or wil have to shoulder a larger
burden in paying for such coverage. This is particularly troublesome given that coverage is provided to a significant percentage of part-time employees who would otherwise have no access to affordable quality health care. Indeed, because of the strains the restricted annual limits place on the collective bargaining process, there is an increased possibilty
that participants wil

lose coverage altogether.

Co m

benefits and specific maximums for which waivers are being sought are set forth in Exhibits A-D attached hereto, to the extent that such maximums are on essential benefits under the PPACA. For clarification purposes, these are designations given by the Fund to the different programs of benefits provided to different classes of employees and retirees:
The classes of

Plan 1

Plan 500

Plan V
Plan S

pl

et eC

ol o

receiving a waiver from the restricted annual limits is the prospect that participants under

ra do .

solvency. As stated above, additional increases in employer and/or employee

co m

that they believe best serves the Fund's participants and dependents and best uses the resources available to fund such benefits. The annual and lifetime limits on certain benefits exist to enable the Fund to provide a full range of benefits and options within the

UFCW L400:000003

Department of Health and Human Services Office of Consumer Information and Office of Oversight ATTN: James Mayhew
December 16, 2010
Page 3

1. Annual Limits.

The Fund provides benefits for a number of classes of individuals covered by the
Fund as set forth in the attached exhibits. Since the Employer contribution rates and

The Trustees have reviewed the cost of increasing the annual benefit limits to comply with the requirements of PP ACA. The Trustees have concluded that increasing the annual benefit maximum to $750,000 per year for the Plan Year beginning February 1, 2011 for all benefit programs wil increase Fund costs significantly, as calculated by the
Fund's consultant. This rise in costs would unexpectedly deplete Fund assets and

reserves. To offset this increase in costs, benefit changes, such as the type and magnitude described in the attached exhibits likely would be required. Accordingly, compliance
with PP ACA's annual benefit limit requirements can be expected to result in a significant

results.

2. Lifetime Limits.

and Health and Human Services, 75 Fed. Reg. 37187 (June 22, 2010), ("Regulations") discuss waivers of the annual limit requirements under Section 1001 of the PP ACA, it

also would be consistent with the purpose of the waiver provision to grant a waiver of the requirement that the Fund eliminate its lifetime limits. The Preamble to the Regulations
indicates that the purpose of the waiver program is to mitigate any unintended

the PPACA's application to plans with low benefit limits. See 75 Fed. Reg. 37187, 37207. The Plans, particularly the retiree programs, have several benefits
consequences of

limits that are low enough to be in the nature of annual limits (for example, all of the

programs have a $Ex. 4

Co m

While the interim final rules issued by the Departments of the Treasury, Labor,

such lifetime limits, such a change likely wil have the direct and unintended

pl

et eC

decrease in access to benefits for those currently covered by the classes of benefits set forth in the attached exhibits and/or a significant increase in premiums paid by those covered by such classes of benefits upon expiration of the current collective bargaining agreements, if not sooner. This waiver application is submitted in order to avoid these

lifetime hospice care limit.) If the Fund is required to remove

ol o

ra do .

participant cost-sharing amounts relating to the benefits described in Exhibits A to Dare fixed under the collective bargaining agreements, the Fund has no abilty to increase its source of funding from employers.

co m

UFCW L400:000004

Department of Health and Human Services Office of Consumer Information and Office of Oversight ATTN: James Mayhew
December 16, 2010
Page 4

forced to either significantly reduce or eliminate categories of benefits or increase

participant cost-sharing for the affected benefits, effective February 1, 2011. Thus, the

Fund's lifetime limits are precisely the types of limits for which Congress intended to
offer relief via the waiver program.
To the extent that the Department of Health and Human Services would deny

the Fund's request for a waiver for its lifetime limits but would grant a waiver for
such limits if they are converted to annual limits as permitted under PP ACA, we

hereby request such a waiver on the grounds that the Board of Trustees wil adopt a
resolution to convert its lifetime limits to annual limits, effective February 1,2011.

Attestation: The undersigned, on behalf of the Board of Trustees, hereby certifies the following:
1. That the Fund was in force prior to September 23, 2010; and
2. That the application of restricted annual limits to the classes set forth in the

attached exhibits is expected to result in a significant decrease in access to benefits for those currently covered by such classes or a significant increase in premiums paid by
those covered by such classes.

Co m

Thank you for your consideration. Please contact the Fund's legal co-counsel, Wiliam Tobin at Reinhart Boerner Van Deuren s.c. (414-298-1000) or Sharon Goodman at Slevin and Hart (202-797-8700) with any questions or requests for additional information.

pl

et eC

ol o
Sincerely,

BOARD OF TRUSTEES OF THE UNITED FOOD AND

COMMERCIAL WORKERS LOCAL 400 AND EMPLOYERS HEALTH AND WELFARE PLAN

By: '-

Title: Employer Trustee

ra do .
Steve~ L er

co m

consequence of significantly decreasing participants' access to benefits or significantly increasing the cost of those benefits. Absent waiver, the Board of Trustees likely wil be

UFCW L400:000005

Health and Human Services Office of Consumer Information and Office of Oversight ATTN: James Mayhew
Department of

December 16, 2010

Page 5

Thomas P. McNutt

Title: Union Trustee

R\5263716_3

Co m

pl

et eC

ol o
UFCW L400:000006

ra do .

Attachments

co m

By:~?ff~

EXHIBIT A
Plan 1

1. Terms. Plan 1 generally covers full-time and part-time employees who

have earned Ex. 4 years of seniority.

2. Number of Individuals Covered. Plan 1 currently covers approximately

3. Current Anual and Lifetime Limits and Rates. Plan 1 provides for limits on benefits as set forth in the Plan document. Select pertinent benefit provisions follow:
Ex. 4

CONVALESCENT CARE

DIABETES EDUCATION

DENTAL

VISION CARE

PHYSICAL EXAMINATION

Co m

pl

et eC
LIFETIME

CHIROPRACTIC SERVICES PER YEAR

LIFETIME BENEFIT MAXIM

SUBSTANCE ABUSE)

INPATIENT & OUTPATIENT (ALCOHOL

PODIATRIST SURGERIE

HOSPICE CARE $5

5263716 A-

ol o
Ex. 4

Ex. 4

ra do .
LrMITS
UFCW L400:000007

co m

Ex. 4

employees.

..

..

BIFE'lII\LIMITS
Ex. 4

GROWTH HORMONES
HEARING AIDS

ORTHODONTIC & PERIODONTIC

Premium.
(a) Anual Limits. If

the Fund is required to remove the annual limits above, the Trustees likely would be required to consider significant benefit changes in
the following changes could be needed to offset the cost of increasing this program's the waiver is not granted (incorporating an increase from an annual maximum of $Ex. 4 the Trustees were to convert the current lifetime maximum to an anual maximum in the event HHS does not grant a waiver with regard to the lifetime maximums as requested below):
annual maximums to $750,000 for the Plan Year beginning February 1,2011, if $750,000 if

ra do .
(from $Ex. 4

order to offset these increased costs. For example, the Fund's consultant estimates that

co m
.

4.

Description of Significant Decrease in Access to Benefits or Increase in

to

Increase annual deductible to $Ex. 4 (from $Ex. 4 .

(b) Lifetime Limits. Similarly, if the Fund is required to remove the

the Plan Year beginning February 1,2011 if

Co m

Increase annual deductible to $Ex. 4 (from $Ex. 4 ).

(from $Ex. 4 ).

Increase annual out-of-pocket maximum to $Ex. 4

( c) Combined Impact of Limits. If the Fund is required to remove the

2011, if

annual and lifetime limits above, the Fund's consultant estimates that the following changes could be needed to offset both costs for the Plan Year beginning February 1, the above lifetime
the waiver is not granted (incorporating the conversion of

maximums to annual maximums):

Increase annual deductible to $ Ex. 4 (from $ Ex. 4 .

Increase annual out-of-pocket maximum to $ Ex. 4

pl

lifetime limits above, the Trustees likely would be required to consider significant benefit changes in order to offset these increased costs. For example, the following changes could be needed to offset the cost of eliminating this program's lifetime maximums for the waiver is not granted:

et eC

Increase annual out-of-pocket maximum to $ Ex. 4

ol o
A-

(from $ Ex. 4

5263716

UFCW L400:000008

The Trustees believe the magnitude of the changes discussed above constitutes a significant decrease in access to benefits for those currently covered by the Plan 1.
Additionally, the Trustees expect the bargaining parties would consider negotiating

increases in the premiums paid by employees covered by Plan 1 at the time of the expiration of the current collective bargaining agreements due to the increased costs
attributed to higher annual benefit limits being extended to Plan 1 participants.

Co m

pl

5263716

et eC
A-

ol o
UFCW L400:000009

ra do .

in #3 above, including an annual maximum of $ Ex. 4 February 1, 2011.

co m

Accordingly, the Trustees request a waiver from the increase in the annual and lifetime essential benefit limits under PP ACA. Specifically, the Trustees request that Plan 1 be allowed to maintain all limits set forth in #3 above for the Plan Year beginning February 1, 2011. In the event that the requested waiver with regard to lifetime limits is denied, the Trustees request that Plan 1 be allowed to maintain the annual limits set forth
for the Plan Year beginning

EXHIBIT B
Plan 500

1.

Terms. Plan 500 covers employees who have less then Ex. 4 years of

seniority .

2. Number of Individuals Covered. Plan 500 currently covers approximately

3. Current Annual and Lifetime Limits and Rates. Plan 500 provides for

limits on benefits as set forth in the Plan document. Select pertinent benefit provisions follow:
Ex. 4

. DIABETES EDUCATION

... i

Co m

..

pl

..

....

LIFETIME BENEFIT MAXIMUM

INPATIENT & OUTPATIENT (ALCOHOL & SUBSTANCE ABUSE)

PODIA TRIST SURGERIES

HOSPICE CARE

5263716

et eC
....

CHIROPRACTIC SERVICES PER YEAR

ol o
Ex. 4

LIFETIM LIMITS
Ex. 4

B-

ra do .
UFCW L400:000010

co m

Ex. 4

employees.

Ex. 4

GROWTH HORMONES

4.

Description of Significant Decrease in Access to Benefits or Increase in

Premium.

above, the Trustees likely would be required to consider significant benefit changes in
order to offset these increased costs. For example, the Fund's consultant estimates that

the following changes could be needed to offset the cost of increasing this program's annual maximums to $750,000 for the Plan Year beginning February 1, 2011, if the

waiver is not granted (incorporating an increase from an annual maximum of$Ex. 4

co m
). ).

(a) Anual Limits. If the Fund is required to remove the annual limits

to

$750,000 if the Trustees were to convert the current lifetime maximum to an annual maximum in the event HHS does not grant a waiver with regard to the lifetime maximums as requested below):
Increase annual deductible to $Ex. 4 (from $ Ex. 4 ).

(b) Lifetime Limits. Similarly, if the Fund is required to remove the

Plan Year beginning February 1, 2011 if the waiver is not granted:

Increase annual deductible to $Ex. 4 (from $Ex. 4 .

Increase annual out-of-pocket maximum to $Ex. 4

pl

et eC
Limits. If

lifetime limits above, the Trustees likely would be required to consider significant benefit changes in order to offset these increased costs. For example, the following change could be needed just to offset the cost of eliminating this program's lifetime maximums for the

ol o
Ex. 4

Increase annual out-of-pocket maximum to $Ex. 4

the Fund is required to remove the annual and lifetime limits above, the Fund's consultant estimates that the following changes could be needed to offset both costs for the Plan Year beginning February 1, 2011, if the waiver is not granted (incorporating the conversion of the above lifetime maximums to annual maximums):
(c) Combined Impact of

Co m

Increase annual deductible to $ Ex. 4 (from $

Increase annual out-of-pocket maximum to $

ra do .
(from $Ex. 4 (from $Ex. 4
.
Ex. 4

(from $ Ex. 4

).

The Trustees believe the magnitude of the changes discussed above constitutes a
significant decrease in access to benefits for those currently covered by Plan 500.

Additionally, the Trustees expect the bargaining parties would consider negotiating

5263716

B-

UFCW L400:000011

increases in the premiums paid by employees covered by Plan 500 at the time of the expiration of the current collective bargaining agreements due to the increased costs
attributed to higher annual benefit limits being extended to Plan 500 participants.

Accordingly, the Trustees request a waiver from the increase in the annual and lifetime essential benefit limits under PP ACA. Specifically, the Trustees request that

Plan 500 be allowed to maintain all limits set forth in #3 above for the Plan Year

Co m

pl

5263716

et eC
B-

ol o
UFCW L400:000012

ra do .

co m

beginning February 1, 2011. In the event that the requested waiver with regard to lifetime limits is denied, the Trustees request that Plan 500 be allowed to maintain the annual limits set forth in #3 above, including an annual maximum of $ Ex. 4 for the Plan Year beginning February 1,2011.

EXHIBIT C
Plan V
1. Terms. Plan V generally covers retirees prior to age 65.

2. Number of Individuals Covered. Plan V currently covers approximately

Ex. 4

employees.

Ex. 4

Ex. 4

LIFETIME BENEFIT MAXIMUM

PODIATRIST SURGERIES

HOSPICE CARE

GROWTH HORMONES

Premium.

limits above, the Trustees likely would be required to consider significant benefit changes

Co m

INPATIENT & OUTPATIENT (ALCOHOL & SUBSTANCE ABUSE)

4.

Description of Significant Decrease in Access to Benefits or Increase in

pl

(a) Anual Limits. If the Fund is required to remove the annual

5263716

et eC
Ex. 4

ol o
CUFCW L400:000013

ra do .

co m

3. Current Anual and Lifetime Limits and Rates. Plan V provides for limits on benefits as set forth in the Plan document. Select pertinent benefit provisions follow:

in order to offset these increased costs. For example, the Fund's consultant estimates that

the following changes could be needed to offset the cost of increasing this program's

annual maximums to $750,000 for the Plan Year beginning February 1, 2011, if the
waiver is not granted (incorporating an increase from an annual maximum of $ Ex. 4 to

$750,000 if the Trustees were to convert the current lifetime maximum to an annual maximum in the event HHS does not grant a waiver with regard to the lifetime maximums as requested below):
Increase annual deductible to $Ex. 4 (from $Ex. 4 ).

Increase annual out-of-pocket maximum to $Ex. 4

(from $Ex. 4

(b) Lifetime Limits. Similarly, if the Fund is required to remove the

lifetime limits above, the Trustees likely would be required to consider significant benefit
could be needed to offset the cost of eliminating this program's lifetime maximums for the waiver is not granted:

the Plan Year beginning February 1,2011 if

Increase annual deductible to $ Ex. 4

(from $Ex. 4 ).

( c) Combined Impact of Limits. If the Fund is required to remove the

annual and lifetime limits above, the Fund's consultant estimates that the following
2011, if the waiver is not granted (incorporating the conversion of the above lifetime

maximums to annual maximums):

Increase annual deductible to $ Ex. 4

et eC

changes could be needed to offset both costs for the Plan Year beginning February 1,

Increase annual out-of-pocket maximum to $ Ex. 4

pl

ol o
C-

Increase annual out-of-pocket maximum to $Ex. 4

ra do .
(from $ Ex. 4 (from $ Ex. 4

changes in order to offset these increased costs. For example, the following changes

(from $ Ex. 4 ).
.

significant decrease in access to benefits for those currently covered by Plan V. Additionally, the Trustees expect to consider increases in the premiums paid by retirees
covered by Plan V due to the increased costs attributed to higher annual benefit limits being extended to Plan V participants.
Accordingly, the Trustees request a waiver from the increase in the annual and

lifetime essential benefit limits under PP ACA. Specifically, the Trustees request that limits set forth in #3 above for the Plan Year beginning February 1, 2011. In the event that the requested waiver with regard to lifetime limits is denied, the Trustees request that Plan V be allowed to maintain the annual limits set forth
Plan V be allowed to maintain all

in #3 above, including an annual maximum of $ Ex. 4

Co m

The Trustees believe the magnitude of the changes discussed above constitutes a

for the Plan Year beginning

February 1,2011.
5263716

co m
). .

UFCW L400:000014

EXHIBIT D
Plan S

1. Terms. Plan S generally covers retirees over age 65. 2. Number of Individuals Covered. Plan S currently covers approximately
Ex. 4

employees.

on benefits as set forth in the Plan document. Select pertinent benefit provisions follow:
Ex. 4

Ex. 4

DIABETES EDUCA nON

et eC

ol o
..

..

...

...

LIFETIME LIMITS
Ex. 4

LIFETIME BENEFIT MAXIMUM

PODIA TRIST SURGERIES PER LIFETIME

HOSPICE CARE PER LIFETIME

Premium.

(a) Annual Limits. If the Fund is required to remove the annual limits above, the Trustees likely would be required to consider significant benefit changes in
order to offset these increased costs. For example, the Fund's consultant estimates that

Co m

INPATIENT & OUTPATIENT (ALCOHOL & SUBSTANCE ABUSE)

4.

Description of Significant Decrease in Access to Benefits or Increase in

pl

5263716

D-

ra do .
UFCW L400:000015

co m

3. Current Annual and Lifetime Limits and Rates. Plan S provides for limits

the following changes could be needed to offset the cost of increasing this program's anual maximums to $750,000 for the Plan Year beginning February 1, 2011, if the

waiver is not granted (incorporating an increase from an annual maximum of$Ex. 4

to

$750,000 if the Trustees were to convert the current lifetime maximum to an annual maximum in the event HHS does not grant a waiver with regard to the lifetime
maximums as requested below):

Increase annual deductible to $Ex. 4 (from $Ex. 4 ).

(b) Lifetime Limits. Similarly, if the Fund is required to remove the

lifetime limits above, the Trustees likely would be required to consider significant benefit

the Plan Year beginning February 1, 2011 if the waiver is not granted:

Increase annual deductible to $Ex. 4 (from $Ex. 4 . Increase annual out-of-pocket maximum to $Ex. 4

ra do .
(from $Ex. 4 (from $ Ex. 4

changes in order to offset these increased costs. For example, the following changes could be needed to offset the cost of eliminating this program's lifetime maximums for

(c) Combined Impact of Limits. If the Fund is required to remove the

annual and lifetime limits above, the Fund's consultant estimates that the following

changes could be needed to offset both costs for the Plan Year beginning February 1,
maximums to annual maximums):

Increase annual deductible to $Ex. 4 (from $ Ex. 4 .

Increase annual out-of-pocket maximum to $ Ex. 4 .

Additionally, the Trustees expect to consider increases in the premiums paid by retirees
covered by Plan S due to the increased costs attributed to higher annual benefit limits being extended to Plan S participants.

Accordingly, the Trustees request a waiver from the increase in the annual and lifetime essential benefit limits under PP ACA. Specifically, the Trustees request that limits set forth in #3 above for the Plan Year beginning February 1, 2011. In the event that the requested waiver with regard to lifetime limits is denied, the Trustees request that Plan S be allowed to maintain the annual limits set forth
Plan S be allowed to maintain all

in #3 above, including an annual maximum of $ Ex. 4

February 1,2011.

Co m

The Trustees believe the magnitude of the changes discussed above constitutes a significant decrease in access to benefits for those currently covered by Plan S.

pl

et eC

2011, if the waiver is not granted (incorporating the conversion of the above lifetime

ol o
D-

5263716

co m
).

Increase annual out-of-pocket maximum to $Ex. 4

(from $Ex. 4

).

for the Plan Year beginning

UFCW L400:000016

United Food and Commercial Workers Local 400 and Employers Health and Welfare Fund
Waiver of Annual Limits Requirements Attachment to Application General The attached spreadsheet has been prepared in a good faith effort to comply with the published requirements for applying for a waiver from PPACA's annual limits. The spreadsheet has been completed in as broad and comprehensive a manner as possible, but its fields should not be interpreted as confirmation that a given benefit is an essential benefit or a benefit for which a waiver is required. Despite the answers given on the spreadsheet, the titles to a number of columns do not fit with the nature of the Fund as a multiemployer plan, as more fully explained below and in the letter enclosed with these materials. That letter provides a more detailed explanation regarding the application, and we refer HHS to that letter for important information regarding the application which cannot be adequately expressed in the spreadsheet. Column AK - AU

Co m

Each of the benefit packages referenced in the United Food and Commercial Workers Local 400 and Employers Health and Welfare Funds waiver application is part of a self insured, multiemployer Taft-Hartley health and welfare fund. Employer contribution rates and Employee contribution rates applicable to certain active employees are established in Collective Bargaining Agreements (CBA) between the Funds contributing employers and the Local Union. As such, employer and employee contributions and coverage tiers vary depending upon the CBA terms. The Trustees who serve as the Fund's administrator and the bargaining parties are bound by the negotiated rates in the CBAs, until the expiration dates of the CBAs. The Trustees also cannot speculate as to whether and how any increased contributions needed to offset the cost of complying with the $750,000 annual limits would be assigned between participants or employers. The principal CBA covering Ex. 4% of all Plan participants will not expire until October 15, 2011. Therefore, the Fund c ot at this point determine how it would cover the additional costs of complying with the annual limits prohibition if the waiver is not granted. Plan 1 and Plan 500 (Active Employees) For the purposes of completing this spreadsheet, the Plan's benefit consultant has included a composite premium equivalent rate in columns AL - AN (Current Monthly Premium Rates or Premium Equivalent Rate) and Columns AO -AQ (Renewal Monthly Premium Rate or Premium Equivalent Rate if Waiver Granted) to show average rates for each plan of benefits and the percentage increases in costs if the waiver is not granted. Since it is currently impossible for the Fund to anticipate how any necessary rate increases would be assigned (between employee and employer contributions) if the

pl

et eC

ol o

ra do .

co m

UFCW L400:000017

waiver is not granted and the Trustees are bound by the negotiated employer contribution rates in the CBAs, the full projected increases are reflected only in the employee contribution rate in column AS. With regard to Plan 1 and Plan 500, the structure of the chart and the percentage reflected in Column AU (Projected Rate Increase that would result from compliance with $750,000 Annual Limit Restriction) does not adequately reflect the potential increase attributed to employee contributions if the waiver is not granted. In the event the waiver is not granted for Plans 1 and Plan 500, employee contributions could increase by the following projected percentages under this approach: UFCW Local 400 & Employers Plan Individual/ Employee Tier

Plans V and Plan S (Retirees)

Co m

With regard to Plan S and Plan V, the security features within the chart made it impossible for the Fund to illustrate the Premium Equivalent for these Plans accurately. Employers do not make a monthly contribution on behalf of each retiree. Instead, the employer contribution for active employees reflects a share of the costs to cover claims and administration for the retirees of the active employers covered by Plan S and Plan V. Retirees of inactive employers pay the full cost of coverage. However, as explained above, the Trustees cannot increase the active employee contribution to offset the cost of complying with the $750,000 annual limits. Therefore, if the cost of coverage increases, the retirees co-payment also likely will increase, even if there is no change in the costsharing percentage. For purposes of completing the chart, only the rates for the employee contribution portions of the premium rates are populated in Columns AL, AO, and AR (Employee Contribution). Because there is no direct monthly employer contribution, the employer contribution rate in Columns AM, AP and AS and Totals in Columns AN, AQ, and AT were left blank. In addition, the Projected Rate Increase that would result from compliance with $750,000 Annual Limit Restriction in Column AU reflects only the increase to the applicable rate for employee contributions.

pl

et eC

ol o
UFCW L400:000018

Plan 1 Plan 1 Plan 1 Plan 1 Plan 500 Plan 500

Employee Employee + Children Employee + Spouse Employee + Family Employee Employee + Family

ra do .
Ex. 4

co m

Projected Percentage Rate Increase that would result from compliance with $750,000 Annual

Column AV - Decrease in Access to Benefits that would Result from compliance with $750,000 Annual Limit Restriction As a multiemployer Taft-Hartley Plan with contribution rates set in collective bargaining agreements, the Board of Trustees is limited in its ability to fund the costs of the annual limits required under PPACA. As the Trustees believe that a waiver of the PPACA annual limits is warranted, no decisions have been made at this time regarding the actual benefit decreases that would be needed to offset a $750,000 annual limit. However, if the waiver is not granted, the Trustees would likely have to consider increases to deductibles and/or increases to the contribution amounts required to be paid by participants. These increases could be unaffordable for a large number of participants who would forego medical care because of the large contributions and deductibles. Please see the accompanying letter and exhibits regarding the level of benefit changes which the Fund's benefit consultant has calculated could be necessary to offset the expected increased costs of complying with the $750,000 annual limit.
333599v1

Co m

pl

et eC

ol o
UFCW L400:000019

ra do .

co m

Annual Limit Waiver Request Applicant Name

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

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) (mm/dd/yyyy) Names State

Street Addresses

Cities

State

Phone Numbers (including Zip Code area code)

ra do .c om
Email Addresses sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

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

Plan 1

Charleston

WV

Co m

UFCW Local 400 and Employers H&W Plan

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

pl

et eC

UFCW Local 400 and Employers H&W Plan

Plan 1

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

DC

20036/53 202

ol o
202-7978700/414298-8279 202-7978700/414298-8279

Group

DC

20036/53 203

Group

UFCW L400:000020

Ex. 4

UFCW Local 400 and Employers H&W Plan

Plan 1

Charleston

WV

01/01/2011

DC

20036/53 204

202-7978700/414298-8279

Plan 1

Charleston

WV

01/01/2011

DC

20036/53 205

ol o
202-7978700/414298-8279 202-7978700/414298-8279

UFCW Local 400 and Employers H&W Plan

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Street Suite Washington/ lliam Tobin Milwaukee 1700

202-7978700/4148700/414 298-8279

UFCW Local 400 and Employers H&W Plan

Plan 500

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee 1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

et eC

DC

20036/53 205

Co m

pl

UFCW Local 400 and Employers H&W Plan

Plan 500

Charleston

WV

01/01/2011

DC

20036/53 205

ra do .c om
sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw co inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

Group

Group

Group

Group

UFCW L400:000021

Ex. 4

Plan V

Charleston

WV

01/01/2011

DC

20036/53 205

UFCW Local 400 and Employers H&W Plan

Plan V

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

DC

20036/53 205

202-7978700/414298-8279

PRA Disclosure Statement

Co m

pl

UFCW Local 400 and Employers H&W Plan

Plan S

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

et eC

UFCW Local 400 and Employers H&W Plan

Plan S

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

DC

20036/53 205

ol o
202-7978700/414298-8279 202-7978700/414298-8279

DC

20036/53 205

ra do .c om
Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

UFCW Local 400 and Employers H&W Plan

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

202-7978700/414298-8279

sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m

Group

Group

Group

Group

UFCW L400:000022

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

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

ra do .c om
Preventive/ Wellness Prescription

Coinsura Coinsura Copay (if Coinsuranc Copay (if nce (if Copay (if nce (if Copay (if Coinsuran ce (if applicabl applicabl applicabl applicabl applicabl e (if applicabl Plan applicable) e) e) e) e) e) applicable) e) Deductible
Ex. 4

Co m

pl

et eC

ol o

UFCW L400:000023

Co m pl et eC

ol o

ra do .c om

Ex. 4

UFCW L400:000024

Co m pl et eC

ol o

ra do .c om

Ex. 4

UFCW L400:000025

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

ra do .c om
Total
Ex. 4

Employee Employer /Retiree Individual/ Employee contribution contribution (if applicable) (if applicable) Tier*

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

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

Plan Administr ator/ CEO of Health Insuranc e Issuer Name

Title of Individual Providing Attestation

et eC

Employee

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

ol o

Fund Administrator

Employee + Children

Co m

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

pl

Fund Administrator

UFCW L400:000026

Employee + Spouse

ra do .c om ol o et eC pl Co m
please l see attached tt h d memo

Ex. 4

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

Fund Administrator

Employee + Family

Board of Trustees Access could of UFCW be restricted Local 400 & due to benefit Employer changes described in s Health & attached Welfare memo. Fund

Fund Administrator

Employee

Access could be restricted due to benefit changes described in attached memo.

Employee + Family

Access could be restricted due to benefit changes described in attached memo.

Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund

Fund Administrator

Fund Administrator

UFCW L400:000027

Employee

ra do .c om ol o et eC
* 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).

Ex. 4

Access could be restricted due to benefit changes described in attached memo.

Employee + Family

Access could be restricted due to benefit changes described in attached memo.

Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund

Fund Administrator

Fund Administrator

Employee

Access could be restricted due to benefit changes described in attached memo.

Co m

pl

Employee + Family

Access could be restricted due to benefit changes described in attached memo.

Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund

Fund Administrator

Fund Administrator

UFCW L400:000028

From: Scelzo, Kathleen (HHS/OCIIO) Sent: Friday, January 28, 2011 1:27 PM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Waiver UFCW LOcal 400 Employers Health and Welfare Fund Attachments: 1-339302-4506_01_110120_Local_400_Waiver_Application_(revised).xls
Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 7501 Wisconsin Avenue Bethesda, MD 301-492-4121

From: Danielle T. Norris [mailto:dnorris@slevinhart.com] Sent: Monday, January 24, 2011 1:37 PM To: Scelzo, Kathleen (HHS/OCIIO) Subject: Waiver

Dear Ms. Scelzo,

If you need anyadditional information, please feel free to call me at 202-797-8700.

Co m

Danielle T. Norris Attorney At Law Slevin & Hart, P.C. 1625 Massachusetts Ave., N.W., Suite 450 Washington, D.C. 20036 202-797-8700 Tel 202-234-8231 Fax dnorris@slevinhart.com

pl

et eC

Best regards, Danielle

ol o

As you requested in ourtelephone discussion on January20th regardingthe waiver application for the UFCW Local 400 and Employers Health and Welfare Fund, attached isa revised spreadsheet that reflectstheincreasesif the waivers are not granted andonlythe employee contributions bear those higher costs.

ra do .

file:////co-adshare/...Mike/United%20Food%20and%20Commercial%20Workers%20Local%20400/Request%20for%20info%201.28.11.htm[11/15/2011 3:33:47 PM]

co m
UFCW L400:000029

From: Scelzo, Kathleen (HHS/OCIIO) Sent: Friday, January 28, 2011 11:29 AM To: 'Danielle T. Norris' Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver UFCW Local 400
Danielle, Can you give me a call please? I need to clarify two more points: Lifetime limits Plan S and V employer contribution Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 7501 Wisconsin Avenue Bethesda, MD 301-492-4121

Importance: High

From: Danielle T. Norris [mailto:dnorris@slevinhart.com] Sent: Monday, January 24, 2011 1:37 PM To: Scelzo, Kathleen (HHS/OCIIO) Subject: Waiver

Dear Ms. Scelzo,

If you need anyadditional information, please feel free to call me at 202-797-8700. Best regards, Danielle

Danielle T. Norris Attorney At Law Slevin & Hart, P.C. 1625 Massachusetts Ave., N.W., Suite 450 Washington, D.C. 20036 202-797-8700 Tel 202-234-8231 Fax dnorris@slevinhart.com

Co m

pl

et eC

As you requested in ourtelephone discussion on January20th regardingthe waiver application for the UFCW Local 400 and Employers Health and Welfare Fund, attached isa revised spreadsheet that reflectstheincreasesif the waivers are not granted andonlythe employee contributions bear those higher costs.

ol o

ra do .
UFCW L400:000030

file:////co-adshare/...20Food%20and%20Commercial%20Workers%20Local%20400/Request%20for%20additional%20info%201.31.11.htm[11/15/2011 3:33:47 PM]

co m

From: Danielle T. Norris [dnorris@slevinhart.com] Sent: Wednesday, February 02, 2011 6:16 PM To: Scelzo, Kathleen (HHS/OCIIO) Cc: Sharon M. Goodman; William H. Tobin Subject: Re: Waiver UFCW Local 400 Importance: High Attachments: 1-333599-Local_400_Waiver_Chart_Explanatory_Memorandum.doc; 1-3432484506_01_110202_Local_400_Waiver_application_chart.xls
Dear Ms. Scelzo, In our telephone discussion on January28th regardingtherevised waiver application for the UFCW Local 400 and Employers Health and Welfare Fund, you indicated thatthe waiver application spreadsheet must include specific dollar figures in the section pertaining to the employer contribution for Plan S and Plan V rather thanreferencethe attachment. As wediscussed,the Fund's application (a copy of which is attached) explains thepremium equivalents and employer contributions for these Plans accurately. However, since you indicated that a numerical entry is required,as you requested, we haverevised the chart toshowa $0 employer contribution for Plan S and Plan Veach monthto reflect that the employer does not pay a separate employer contribution for each retiree each month. Best regards, Danielle Danielle T. Norris Attorney At Law Slevin & Hart, P.C. 1625 Massachusetts Ave., N.W., Suite 450 Washington, D.C. 20036 202-797-8700 Tel 202-234-8231 Fax dnorris@slevinhart.com

Danielle, Can you give me a call please? I need to clarify two more points: Lifetime limits Plan S and V employer contribution Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 7501 Wisconsin Avenue Bethesda, MD 301-492-4121

From: Danielle T. Norris [mailto:dnorris@slevinhart.com] Sent: Monday, January 24, 2011 1:37 PM
UFCW L400:000031

file:////co-adshare/...20Team/Mike/United%20Food%20and%20Commercial%20Workers%20Local%20400/Correspondence%202.2.11.htm[11/15/2011 3:33:47 PM]

Co m

pl

From: Scelzo, Kathleen (HHS/OCIIO) [mailto:Kathleen.Scelzo@hhs.gov] Sent: Friday, January 28, 2011 11:29 AM To: Danielle T. Norris Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver UFCW Local 400 Importance: High

et eC

ol o

ra do .

co m

To: Scelzo, Kathleen (HHS/OCIIO) Subject: Waiver

Dear Ms. Scelzo, As you requested in ourtelephone discussion on January20th regardingthe waiver application for the UFCW Local 400 and Employers Health and Welfare Fund, attached isa revised spreadsheet that reflectstheincreasesif the waivers are not granted andonlythe employee contributions bear those higher costs.

If you need anyadditional information, please feel free to call me at 202-797-8700. Best regards, Danielle Danielle T. Norris Attorney At Law Slevin & Hart, P.C. 1625 Massachusetts Ave., N.W., Suite 450 Washington, D.C. 20036 202-797-8700 Tel 202-234-8231 Fax dnorris@slevinhart.com

Co m

pl

et eC

ol o
UFCW L400:000032

file:////co-adshare/...20Team/Mike/United%20Food%20and%20Commercial%20Workers%20Local%20400/Correspondence%202.2.11.htm[11/15/2011 3:33:47 PM]

ra do .

co m

Annual Limit Waiver Request Applicant Name

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

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) (mm/dd/yyyy) Names State

Street Addresses

Cities

State

Phone Numbers (including Zip Code area code)

ra do .c om
Email Addresses sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

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

Plan 1

Charleston

WV

Co m

UFCW Local 400 and Employers H&W Plan

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

pl

et eC

UFCW Local 400 and Employers H&W Plan

Plan 1

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

DC

20036/53 202

ol o
202-7978700/414298-8279 202-7978700/414298-8279

Group

DC

20036/53 203

Group

UFCW L400:000033

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

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

ra do .c om
Preventive/ Wellness Prescription

Coinsura Coinsura Copay (if Coinsuran Copay (if nce (if Copay (if Coinsuranc Copay (if nce (if ce (if applicabl applicabl applicabl applicabl applicabl e (if applicabl Plan applicable) e) e) e) e) e) applicable) e) Deductible
Ex. 4

Co m

pl

et eC

ol o

UFCW L400:000034

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

ra do .c om
Total
Ex. 4

Employee Employer /Retiree Individual/ Employee contribution contribution (if applicable) (if applicable) Tier*

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

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

Plan Administr ator/ CEO of Health Insuranc e Issuer Name

Title of Individual Providing Attestation

et eC

Employee

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

ol o

Fund Administrator

Employee + Children

Co m

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

pl

Fund Administrator

UFCW L400:000035

Annual Limit Waiver Request Applicant Name

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

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) (mm/dd/yyyy) Names State

Street Addresses

Cities

State

Phone Numbers (including Zip Code area code)

ra do .c om
Email Addresses sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

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

Co m

UFCW Local 400 and Employers H&W Plan

Plan 1

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

pl

et eC

UFCW Local 400 and Employers H&W Plan

Plan 1

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

DC

20036/53 204

ol o
202-7978700/414298-8279 202-7978700/414298-8279

Group

DC

20036/53 205

Group

UFCW L400:000036

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

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

ra do .c om
Preventive/ Wellness Prescription

Coinsura Coinsura Copay (if Coinsuran Copay (if nce (if Copay (if Coinsuranc Copay (if nce (if ce (if applicabl applicabl applicabl applicabl applicabl e (if applicabl Plan applicable) e) e) e) e) e) applicable) e) Deductible
Ex. 4

Co m

pl

et eC

ol o

UFCW L400:000037

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

ra do .c om
Total
Ex. 4

Employee Employer /Retiree Individual/ Employee contribution contribution (if applicable) (if applicable) Tier*

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

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

Plan Administr ator/ CEO of Health Insuranc e Issuer Name

Title of Individual Providing Attestation

et eC

Employee + Spouse

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

ol o

Fund Administrator

Employee + Family attached memo attached memo attached memo

Co m

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund attached memo

pl

Fund Administrator

attached memo

attached memo

attached memo

attached memo

attached memo

Please see attached memo

UFCW L400:000038

Annual Limit Waiver Request Applicant Name

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

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) (mm/dd/yyyy) Names State

Street Addresses

Cities

State

Phone Numbers (including Zip Code area code)

ra do .c om
Email Addresses sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

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

Plan 500

Charleston

WV

01/01/2011

DC

20036/53 205

ol o
202-7978700/414298-8279 202-7978700/414298-8279

UFCW Local 400 and Employers H&W Plan

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee 1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

202-7978700/414298-8279

Group

UFCW Local 400 and Employers H&W Plan

et eC
20036/53 205

Plan 500

Charleston

WV

01/01/2011

DC

Group

UFCW Local 400 and Employers H&W Plan

Co m

Plan V

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

pl
20036/53 205

DC

Group

UFCW L400:000039

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

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

ra do .c om
Preventive/ Wellness Prescription

Coinsura Coinsura Copay (if Coinsuran Copay (if nce (if Copay (if Coinsuranc Copay (if nce (if ce (if applicabl applicabl applicabl applicabl applicabl e (if applicabl Plan applicable) e) e) e) e) e) applicable) e) Deductible
Ex. 4

Co m

pl

et eC

ol o

UFCW L400:000040

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

ra do .c om
Total
Ex. 4

Employee Employer /Retiree Individual/ Employee contribution contribution (if applicable) (if applicable) Tier*

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

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

Employee

ol o

Access could be restricted due to benefit changes described in attached memo.

Employee + Family

et eC

Access could be restricted due to benefit changes described in attached memo.

Plan Administr ator/ CEO of Health Insuranc e Issuer Name Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund

Title of Individual Providing Attestation

Fund Administrator

Fund Administrator

pl

Employee

Co m

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

Fund Administrator

UFCW L400:000041

Annual Limit Waiver Request Applicant Name

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

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) (mm/dd/yyyy) Names State

Street Addresses

Cities

State

Phone Numbers (including Zip Code area code)

ra do .c om
Email Addresses sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes sgoodman@ slevinhart.co m/wtobin@re inhartlaw.co m Other Yes

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

Plan V

Charleston

WV

01/01/2011

DC

20036/53 205

ol o
202-7978700/414298-8279 202-7978700/414298-8279

UFCW Local 400 and Employers H&W Plan

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

202-7978700/414298-8279

Group

UFCW Local 400 and Employers H&W Plan

Plan S

Charleston

WV

01/01/2011

1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee 1625 Massachuset ts Ave NW, Suite 450/1000 Sharon M. North Water Goodman/Wi Street, Suite Washington/ lliam Tobin 1700 Milwaukee

et eC
20036/53 205

DC

Group

UFCW Local 400 and Employers H&W Plan

Co m

Plan S

Charleston

WV

pl
DC 20036/53 205

01/01/2011

Group

UFCW L400:000042

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

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

ra do .c om
Preventive/ Wellness Prescription

Coinsura Coinsura Copay (if Coinsuran Copay (if nce (if Copay (if Coinsuranc Copay (if nce (if ce (if applicabl applicabl applicabl applicabl applicabl e (if applicabl Plan applicable) e) e) e) e) e) applicable) e) Deductible
Ex. 4

Co m

pl

et eC

ol o

UFCW L400:000043

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

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

ra do .c om
Total
Ex. 4

Employee Employer /Retiree Individual/ Employee contribution contribution (if applicable) (if applicable) Tier*

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

Total

Employee/Ret Employer iree contribution contribution (if applicable) (if applicable)

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

Plan Administr ator/ CEO of Health Insuranc e Issuer Name

Title of Individual Providing Attestation

Employee + Family

ol o

Board of Trustees Access could of UFCW be restricted Local 400 due to benefit & changes Employer described in s Health & attached Welfare memo. Fund

Fund Administrator

Employee

Access could be restricted due to benefit changes described in attached memo.

Employee + Family

Co m

Access could be restricted due to benefit changes described in attached memo.

Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund Board of Trustees of UFCW Local 400 & Employer s Health & Welfare Fund

et eC

Fund Administrator

pl

Fund Administrator

* 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, t ) li bl If i l id th i t i th l titl d "T t l" (C l AN AQ d AT)

UFCW L400:000044

From: Botwinick, Alexandra (HHS/OCIIO) Sent: Thursday, February 03, 2011 2:49 PM To: 'sgoodman@slevinhart.com'; 'wtobin@reinhartlaw.com' Cc: Habit, Sandra (HHS/OCIIO) Subject: UFCW Local 400 and Employers H&W Plan Waiver of the Annual Limits Requirements 2-3-2011 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 UFCW Local 400 and Employers H&W Plan. HHS has reviewed your application and made its determination. Please see the attached letter. The attached letter refers to the following plans:
Plan 1

Plan 500

Plan S

alexandra.botwinick@hhs.gov

Co m

Alexandra Botwinick Office of Oversight HHS/OCIIO

pl

Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance.

et eC

ol o

UFCW L400:000045

file:////co-adshare/...ssing%20Team/Mike/United%20Food%20and%20Commercial%20Workers%20Local%20400/Approval%202.3.11.htm[11/15/2011 3:33:59 PM]

ra do .

co m

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

UFCW L400:000046

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

UFCW L400:000047

From: Scelzo, Kathleen (HHS/OCIIO) Sent: Tuesday, February 15, 2011 11:11 AM To: 'sgoodman@slevinhart.com' Cc: 'wtobin@reinhartlaw.com' Subject: UFCW Local 400 Limited Waiver Approval Attachments: Jan 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 UFCW Local 400 HHS has reviewed your application and made its determination. Please see the attached letter. The attached letter refers to the following plans: Plan V Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance.
Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 7501 Wisconsin Avenue Bethesda, MD 301-492-4121

Co m

pl

et eC

ol o
UFCW L400:000048

file:////co-adshare/...mercial%20Workers%20Local%20400/UFCW%20Local%20400%20Limited%20Waiver%20Approval%202.15.11.htm[11/15/2011 3:33:59 PM]

ra do .

co m

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

UFCW L400:000049

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

UFCW L400:000050