southeast laborers - redacted bates hw

7/27/2019 Southeast Laborers - Redacted Bates HW

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

rom: Donny Dowlen [[email protected]]

ent: Monday, January 03, 2011 4:34 PM

o: HHS HealthInsurance (HHS)

ubject: Waiver

ttachments: 13115.pdf

ncl osed i s document at i on f or t he Sout heast Laborer s Heal t h Fund.

onny Dowl enout her n Benef i t Admi ni st r at or s00- 831- 4914

r i v a cy a n d Co n f i d e n t i a l i t y N o t i c e : This message is being sent via secure SSL encryption to protect the priv

f our clients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attac

r embedded documents) is intended for the exclusive and confidential use of the individual or entity to which

as been addressed, and unless otherwise expressly indicated, is confidential and privileged information of

outhern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is

rohibited. If you receive this transmission in error, please notify us immediately by e-mail at

[email protected], and delete the original message. Your cooperation is appreciated.

SE Laborers:000001

Document obtained by CompleteColorado.com
mailto:[email protected]:[email protected]


2/34

SE Laborers:000002



3/34

SE Laborers:000003



4/34



5/34

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

SE Laborers:000005



6/34

Annual L imit

Waiver

Request

Appl icant

Name

Policy Name

(use a new

row for each

policy

application)

Appl icant

(Plan/ Policy

Situs) City

Appl icant

(Plan/

Policy

Situs) State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Address City

Applicant

ABC Silver Plan Washington DC 01/01/2011 J ane Doe

100 ABC

Drive WashingtonApplicant


100 ABC

Drive Washington

Applicant


100 ABC

Drive Washington

Applicant


100 ABC

Drive Washington

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund Goodlettsville TN 04/01/2011

Donny

Dowlen

2001

Caldwell

Drive Goodlettsvil

Southeast

Laborers

Health Fund

Southeast

Laborers


Donny

Dowlen

2001

Caldwell

Drive Goodlettsvil

Southeast

Laborers

Health Fund

Southeast

Laborers


Donny

Dowlen

2001

Caldwell

Drive Goodlettsvil

Southeast

Laborers

Health Fund

Southeast

Laborers


Donny

Dowlen

2001

Caldwell

Drive Goodlettsvil



7/34

Annual L imit

Waiver

Request

Appl icant

Name

Applicant

ABCApplicant

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-xxx-

xxx)

Email

Address

Type of

Coverage (e.g.,

Limited

Benefit, HRA,

Rx only, Other)

Self-

Insured

Individual or

Group Policy

Total Number

of

Individuals

Covered by

Policy

(include all

dependents

covered)

Current Plan

Annual L imit

(in dollars)

1-800-ABC-

1234

abc@abcheal

thplan.com Limited Benefit Yes Group 4,000 $100,0001-800-ABC-

1234

abc@abcheal

thplan.com Limited Benefit Yes Group 2,500 $100,000

1-800-ABC-

1234

abc@abcheal


1-800-ABC-

1234

abc@abcheal


1-800-831-

4914

donny.dowlen

@southernbe

nefit.com Limited Benefit Yes Group

1-800-831-

4914

donny.dowlen

@southernbe


1-800-831-

4914

donny.dowlen

@southernbe


1-800-831-

4914

donny.dowlen

@southernbe




8/34

Annual L imit

Waiver

Request

Appl icant

Name

Applicant

ABCApplicant

ABC

Applicant

ABC

Applicant

ABC

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Emergency Hospitalization Laboratory Pediatric

Maternity/

Newborn

Mental H

Substan

Abuse

$5,000 None None None None N




none none none none none no






9/34

Annual L imit

Waiver

Request

Appl icant

Name

Applicant

ABCApplicant

ABC

Applicant

ABC

Applicant

ABC

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Preventive/

Wellness Prescription

Plan

Deductible

Copay (if

applicable

)

Coinsuranc

e (if

applicable)

Copay (if

applicable

)

Coinsura

nce (if

applicable

)

Co

ap

)

None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $

None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $

None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $

None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $

none

none

none

none



10/34

Annual L imit

Waiver

Request

Appl icant

Name

Applicant

ABCApplicant

ABC

Applicant

ABC

Applicant

ABC

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Coinsurance

(if applicable)

Individual/

Employee

Tier*

Employee

contribution

Employer

contr ibuti on Total

Employee

contribution

Em

con

None Employee $100.00 $600.00 $700.00 $110.00

None

Employee +

Child $150.00 $700.00 $850.00 $150.00

None

Employee +

Spouse $150.00 $800.00 $950.00 $150.00

None

Employee +

Family $150.00 $1,100.00 $1,250.00 $150.00 $



11/34

Annual L imit

Waiver

Request

Appl icant

Name

Applicant

ABCApplicant

ABC

Applicant

ABC

Applicant

ABC

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Employee

contribution

Employer

contribution Total

Projected Rate Increase

that would result from

compliance with $750,000

Annual L imit Restrict ion (in

dollars)(Average Premium

by Individual) (Difference

of Column AV and AS

divided by Column AS)

Decre

Acces

Benef

would

from

comp

with $

Annua

Restr

(desc

briefly

$250.00 $800.00 $1,050.00 38.16%

Term

the

$250.00 $900.00 $1,150.00 27.78%

Term

the

$250.00 $975.00 $1,225.00 22.50%

Term

the

$250.00 $1,400.00 $1,650.00 26.92%

Term

the

for

elimi

non e

for

elimi

non e

truste

for

elimi

non e

forelimi

non e

bene



12/34

Annual L imit

Waiver

Request

Appl icant

Name

Applicant

ABCApplicant

ABC

Applicant

ABC

Applicant

ABC

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Southeast

Laborers

Health Fund

Taft-Hartley

Plan

If Yes Taft-

Hartley then

Date

Collective

Bargaining

Agreement

Expires

Compliance

with

Grandfather

Regulation

Lead

Reviewer

Date of

Receipt

Yes 01/01/2013 Yes E. Pham 09/01/2010

Yes 01/01/2013 Yes E. Pham 09/01/2010

Yes 01/01/2013 Yes E. Pham 09/01/2010

Yes 01/01/2013 Yes E. Pham 09/01/2010

yes 12/31/2011 yes

yes 12/31/2011 yes

yes 12/31/2011 yes

yes 12/31/2011 yes



13/34

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

rom: Moultrie, Cam (HHS/OCIIO)ent: Monday, January 31, 2011 12:39 PM

To: Donny DowlenCc: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Southeast Laborers Health Fundhank 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 spreadsheto this email address as an attachment. We will only be able to process spreadsheets that are fully comp(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain tyour plan, please write None, and/or provide an explanation regarding why you are unable to completethat 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.

n order to complete your application, please provide this information by 5:00 pm, February 3, 2011. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

his information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

rom: Donny Dowlen [mailto:[email protected]]ent: Monday, January 03, 2011 4:34 PMo: HHS HealthInsurance (HHS)ubject: Waiver

nclosed is documentation for the Southeast Laborers Health Fund.

onny Dowlenouthern Benefit Administrators00-831-4914




SE Laborers:000013



14/34

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



rohibited. If you receive this transmission in error, please notify us immediately by e-mail at

[email protected], and delete the original message. Your cooperation is appreciated.

SE Laborers:000014



15/34

//T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20info%20response%202.1.11.htm[08/11/2011 10:58:3

rom: Donny Dowlen [[email protected]]ent: Tuesday, February 01, 2011 3:13 PM

To: Moultrie, Cam (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)

ubject: RE: Waiver Application for Southeast Laborers Health Fund

Attachments: 21116.xlsnclosed is the completed spreadsheet. Note that there is only one tier of employees covered ll employees pay the same amount for their coverage. It is therefore not necessary that we k

overage by employee, employee/child, employee/family, etc. An employee who is single pays thame as the employee with a wife and 3 children. Its the way these types of union fundsypically operate. There are no separate rates.

e have responded to your questions below. Let us know if you need anything else.

onny Dowlen

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 31, 2011 11:39 AMo: Donny Dowlenc: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Southeast Laborers Health Fund

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

Please complete the entire annual limits spreadsheet available at:ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to this eddress as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell shouontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None,nd/or provide an explanation regarding why you are unable to complete that particular cell in a separate document

I. 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 withrandfathering provisions, pursuant to 45 CFR 147.140?

Yes and yes as noted in our initial submission


Yes, as noted in our initial submission. - $ maximum lifetime

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

Yes with expiration date of 12/31/2011 as noted in our initial submissionn order to complete your application, please provide this information by 5:00 pm, February 3, 2011. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humaervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

SE Laborers:000015



16/34

//T|/...20Response%20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20info%20response%202.1.11.htm[08/11/2011 10:58:3

hank you.


This information has not been publicly disclosed and may be privileged and confidential. It is for internal governm

use only and must not be disseminated, distributed, or copied to persons not authorized to receive the informatioUnauthorized disclosure may result in prosecution to the full extent of the law.

rom: Donny Dowlen [mailto:[email protected]]ent: Monday, January 03, 2011 4:34 PM

To: HHS HealthInsurance (HHS)ubject: Waiver


Donny Dowlen

outhern Benefit Administrators00-831-4914

rivacy and Confidentiality Notice: This message is being sent via secure SSL encryption to protect the privacy oflients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached ormbedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has bddressed, 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 receivhis transmission in error, please notify us immediately by e-mail at [email protected], and delete theriginal message. Your cooperation is appreciated.

rivacy 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.urthermore, 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 addresnd unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosaterial is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at [email protected], and delete the original message. Your cooperappreciated.

SE Laborers:000016



17/34

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

rom: Moultrie, Cam (HHS/OCIIO)ent: Wednesday, February 02, 2011 10:04 AM

To: Donny DowlenCc: Habit, Sandra (HHS/OCIIO)

ubject: RE: Waiver Application for Southeast Laborers Health Fundursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 20xcept in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously hadfetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of the

lan. Please confirm whether this lifetime limit will be eliminated from your plan.

hank you.




rom: Donny Dowlen [mailto:[email protected]]ent: Tuesday, February 01, 2011 3:13 PMo: Moultrie, Cam (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for Southeast Laborers Health Fund

nclosed is the completed spreadsheet. Note that there is only one tier of employees covered ll employees pay the same amount for their coverage. It is therefore not necessary that we koverage by employee, employee/child, employee/family, etc. An employee who is single pays thame as the employee with a wife and 3 children. Its the way these types of union fundsypically operate. There are no separate rates.

e have responded to your questions below. Let us know if you need anything else.

onny Dowlen

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 31, 2011 11:39 AMo: Donny Dowlenc: Habit, Sandra (HHS/OCIIO)ubject: Waiver Application for Southeast Laborers Health Fund


Please complete the entire annual limits spreadsheet available at:

ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to this eddress as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell shouontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None,nd/or provide an explanation regarding why you are unable to complete that particular cell in a separate document


SE Laborers:000017



18/34







Yes with expiration date of 12/31/2011 as noted in our initial submissionn order to complete your application, please provide this information by 5:00 pm, February 3, 2011. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you.


This information has not been publicly disclosed and may be privileged and confidential. It is for internal governmuse only and must not be disseminated, distributed, or copied to persons not authorized to receive the informatio

Unauthorized disclosure may result in prosecution to the full extent of the law.




Donny Dowlenouthern Benefit Administrators00-831-4914

Privacy and Confidential ity Notice:This message is being sent via secure SSL encryption to protect the privacy oflients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached ormbedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has bddressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit


ri vacy and Confi dentiali ty Notice:This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure

ompliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive

onfidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privile

SE Laborers:000018



19/34


formation of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you

eceive this transmission in error, please notify us immediately by e-mail at [email protected], and delete the original message. You

ooperation is appreciated.

SE Laborers:000019



20/34

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

rom: Donny Dowlen [[email protected]]ent: Wednesday, February 02, 2011 3:23 PM

To: Moultrie, Cam (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell'

ubject: RE: Waiver Application for Southeast Laborers Health Fundam, thank you for the email. As you know, the lifetime limit must be removed before theeginning of the plan year on or after September 23, 2010. For this plan, the first plan yeafter September 23, 2010 is April 1, 2011. The lifetime limit will be removed by April 1, 20nd the trustees intend to maintain the plans grandfather status. Let me know if you neednything thing else regarding this application. Thank you.

onny Dowlen

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, February 02, 2011 9:04 AMo: Donny Dowlenc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for Southeast Laborers Health Fund

ursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 20xcept in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously hadfetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of the

lan. Please confirm whether this lifetime limit will be eliminated from your plan.

hank you.




rom: Donny Dowlen [mailto:[email protected]]ent: Tuesday, February 01, 2011 3:13 PM



nclosed is the completed spreadsheet. Note that there is only one tier of employees covered as all employees pay ame amount for their coverage. It is therefore not necessary that we keep coverage by employee, employee/child,mployee/family, etc. An employee who is single pays the same as the employee with a wife and 3 children. Its

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

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Monday, January 31, 2011 11:39 AM


ubject: Waiver Application for Southeast Laborers Health FundSE Laborers:000020



21/34



Please complete the entire annual limits spreadsheet available at:ttp://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to this eddress as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., every cell shouontain the information requested). If a cell on the spreadsheet does not pertain to your plan, please write None,

nd/or provide an explanation regarding why you are unable to complete that particular cell in a separate document








hank you.







Donny DowlenSE Laborers:000021



22/34


outhern Benefit Administrators00-831-4914


Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receiv

his transmission in error, please notify us immediately by e-mail at [email protected], and delete theriginal message. Your cooperation is appreciated.



rivacy 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.urthermore, 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 addred unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclos

aterial is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at [email protected], and delete the original message. Your cooperappreciated.

SE Laborers:000022



23/34

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

rom: Moultrie, Cam (HHS/OCIIO)ent: Thursday, February 03, 2011 11:55 AM

To: Donny DowlenCc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell'

ubject: RE: Waiver Application for Southeast Laborers Health Fundlease breakdown the number of employees in each employee tier.




rom: Donny Dowlen [mailto:[email protected]]ent: Wednesday, February 02, 2011 3:23 PMo: Moultrie, Cam (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell'ubject: RE: Waiver Application for Southeast Laborers Health Fund

am, thank you for the email. As you know, the lifetime limit must be removed before theeginning of the plan year on or after September 23, 2010. For this plan, the first plan yeafter September 23, 2010 is April 1, 2011. The lifetime limit will be removed by April 1, 20nd the trustees intend to maintain the plans grandfather status. Let me know if you neednything thing else regarding this application. Thank you.

onny Dowlen

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, February 02, 2011 9:04 AMo: Donny Dowlenc: Habit, Sandra (HHS/OCIIO)ubject: RE: Waiver Application for Southeast Laborers Health Fund

ursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 20xcept in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously hadfetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of thelan. Please confirm whether this lifetime limit will be eliminated from your plan.

hank 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 governm





SE Laborers:000023



24/34





Donny Dowlen



ubject: Waiver Application for Southeast Laborers Health Fund










hank you.

SE Laborers:000024



25/34








Donny Dowlenouthern Benefit Administrators00-831-4914

Privacy and Confidential ity Notice:This message is being sent via secure SSL encryption to protect the privacy of

lients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached ormbedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has bddressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit


Privacy and Confidential ity Notice:This message is being sent via secure SSL encryption to protect the privacy oflients and to ensure compliance with HIPAA regulations. Furthermore, this message (including any attached ormbedded documents) is intended for the exclusive and confidential use of the individual or entity to which it has b

ddressed, and unless otherwise expressly indicated, is confidential and privileged information of Southern BenefitAdministrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you receivhis transmission in error, please notify us immediately by e-mail at [email protected], and delete theriginal message. Your cooperation is appreciated.

ri vacy and Confi dentiali ty Notice:This message is being sent via secure SSL encryption to protect the privacy of our clients and to ensure

ompliance with HIPAA regulations. Furthermore, this message (including any attached or embedded documents) is intended for the exclusive

onfidential use of the individual or entity to which it has been addressed, and unless otherwise expressly indicated, is confidential and privile

formation of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclosed material is prohibited. If you

eceive this transmission in error, please notify us immediately by e-mail at [email protected], and delete the original message. You

ooperation is appreciated.

SE Laborers:000025



26/34

//T|/...20[YELLOW]/Southeast%20Laborers%20Health%20Fund/Request%20for%20additional%20info%20response%202.3.11.htm[08/11/2011 10:58:3

rom: Donny Dowlen [[email protected]]ent: Thursday, February 03, 2011 12:24 PM


ubject: RE: Waiver Application for Southeast Laborers Health Fundam, please note my response to you on 2/1/11. There is only one tier of employees since theyll pay the same regardless of how many are covered in the family. Its the typical way Taftartley union plans work. It is not necessary for us to keep records broken down by tier andhis is not something we have. Please let me know if you need anything else.

onny Dowlen

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Thursday, February 03, 2011 10:55 AMo: Donny Dowlenc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell'ubject: RE: Waiver Application for Southeast Laborers Health Fund

lease breakdown the number of employees in each employee tier.




rom: Donny Dowlen [mailto:[email protected]]ent: Wednesday, February 02, 2011 3:23 PM

To: Moultrie, Cam (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO); 'Jere T. Brassell'


Cam, thank you for the email. As you know, the lifetime limit must be removed before the beginning of the plan yn or after September 23, 2010. For this plan, the first plan year after September 23, 2010 is April 1, 2011. Thefetime limit will be removed by April 1, 2011 and the trustees intend to maintain the plans grandfather status. Le

me know if you need anything thing else regarding this application. Thank you.

Donny Dowlen

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Wednesday, February 02, 2011 9:04 AM



ursuant to Section 2711 of the PHS Act, you may not have any lifetime limit on your plan as of September 23, 20xcept in the case of non-essential benefits that are permitted under Federal or State law. Plans that previously hadfetime limit may add an annual limit not less than the lifetime limit without affecting the grandfather status of thelan. Please confirm whether this lifetime limit will be eliminated from your plan.

hank you.

SE Laborers:000026



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Donny Dowlen










SE Laborers:000027



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Yes with expiration date of 12/31/2011 as noted in our initial submissionn order to complete your application, please provide this information by 5:00 pm, February 3, 2011. Once thisnformation is received and the application is complete, it will be processed by the Department of Health and Humervices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 3

ays of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decisi

hank you.







Donny Dowlenouthern Benefit Administrators

00-831-4914





SE Laborers:000028



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rivacy 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.urthermore, 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 addred unless otherwise expressly indicated, is confidential and privileged information of Southern Benefit Administrators, Inc. Any dissemination, distribution or copying of the enclos

aterial is prohibited. If you receive this transmission in error, please notify us immediately by e-mail at [email protected], and delete the original message. Your cooperappreciated.

SE Laborers:000029



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

rom: Moultrie, Cam (HHS/OCIIO)

ent: Monday, February 14, 2011 11:18 AM

o: 'Donny Dowlen'


ttachments: April 1 Approval .pdf

ood Morning,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711

outheast Laborers Health Fund. HHS has reviewed your application and made its determination. Please see the attac

etter.

he attached letter refers to the following plans:

Southeast Laborers Health Fund

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

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

am Lynne Moultrie

ivision of Oversight

enter for Consumer Information and Insurance Oversight

.S. Department of Health & Human Services

01.492.4174

[email protected]




SE Laborers:000030



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SE Laborers:000031



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SE Laborers:000032



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

rom: Donny Dowlen [[email protected]]

ent: Monday, February 14, 2011 3:39 PM

o: Moultrie, Cam (HHS/OCIIO)


eceipt confirmed.

rom: Moultrie, Cam (HHS/OCIIO) [mailto:[email protected]]ent: Monday, February 14, 2011 10:18 AMo: Donny Dowlenubject: Waiver Application for Southeast Laborers Health Fund

Good Morning,

hank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2orSoutheast Laborers Health Fund. HHS has reviewed your application and made its determination. Please see thttached letter.

he attached letter refers to the following plans:

Southeast Laborers Health Fund

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

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

Cam Lynne Moultrie

Division of OversightCenter for Consumer Information and Insurance OversightU.S. Department of Health & Human [email protected]









rohibited. If you receive this transmission in error, please notify us immediately by e-mail atSE Laborers:000033

mailto:[mailto:[email protected]]mailto:[email protected]:[email protected]:[mailto:[email protected]]


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[email protected], and delete the original message. Your cooperation is appreciated.Document obtained by CompleteColorado.com

southeast laborers - redacted bates hw

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