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8/22/2019 Ulster Greene ARC - Combined Redacted-Bates HW

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UlsterGreene:000001


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UlsterGreene:000002


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

UlsterGreene:000003


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

rom: Sheer, Jennifer (HHS/OCIIO)

ent: Monday, December 20, 2010 2:53 PM

o: '[email protected]'

ubject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application

ttachments: Waiver Application Form.xls

ollow Up Flag: Follow up

ag Status: Completed

Dear Applicant:

hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:

I. Please complete the entire annual limits spreadsheet, attached to this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet donot pertain to your plan, please write None, and/or provide an explanation regarding why you are unabto complete that particular cell in a separate document.

II. In addition, please provide the following information:

Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance withgrandfathering provisions, pursuant to 45 CFR 147.140?

Confirm whether the plan was created pursuant to the Taft-Hartley Act. If yes:

o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008.

o Please provide the date for which the Collective Bargaining Agreement will expire.

n order to complete your application, please provide this information by 5:00 pm, December 21, 2010. 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.

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

ennifer L. O. Sheer

ffice of Consumer Support

ffice of Consumer Information and Insurance Oversight

.S. Department of Health and Human Services

[email protected]

01-492-4487

UlsterGreene:000004
mailto:[email protected]:[email protected]


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rom: John McHugh [[email protected]]

ent: Tuesday, December 21, 2010 4:01 PM

o: Sheer, Jennifer (HHS/OCIIO)

c: Mark Vanyo

ubject: RE: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application

ttachments: Copy of Waiver Application Form (Final)UGARC.xls



ear Ms. Sheer:

n regards to our application for the Waiver of the Annual Limits Requirements of the Public Health Service Act (PHS Act).

lease find attached the completed annual limits spreadsheet. In addition, please find the information requested in Part I

nswered in red.

you have any questions or need any additional information, please do not hesitate to contact me.

hank you.

ohn

ohn McHugh

hief Financial Officer

lster-Greene ARC

71 Albany Avenue

ingston, NY 12401

hone: (845) 331-4300 Ext. 256

ax: (845) 331-4931

mail:[email protected]

Mission: " To offer people with intellectual and other developmental disabilities opportunities to live and experie

full lives".

To donate to Ulster-Greene ARC Foundation, click on the donate button below. Thank you for your supp

rom: Sheer, Jennifer (HHS/OCIIO) [mailto:[email protected]]ent: Monday, December 20, 2010 2:53 PMo: John McHughubject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application

UlsterGreene:000005
mailto:[email protected]:[mailto:[email protected]]mailto:[mailto:[email protected]]mailto:[mailto:[email protected]]https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=5713025mailto:[email protected]


6/14


Dear Applicant:

hank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service ActPHS Act) Section 2711. In order to expedite your application, please provide the following information:

I. Please complete the entire annual limits spreadsheet, attached to this email. Please return the completedspreadsheet to this email address as an attachment. We will only be able to process spreadsheets that arfully complete (i.e., every cell should contain the information requested). If a cell on the spreadsheet donot pertain to your plan, please write None, and/or provide an explanation regarding why you are unab

to complete that particular cell in a separate document.

II. In addition, please provide the following information:

Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with

grandfathering provisions, pursuant to 45 CFR 147.140? Yes, the plan was in existence prior to March 22010. No, we are NOT grandfathering the plan for purposes of this waiver.

Confirm whether the plan was created pursuant to the Taft-Hartley Act. If yes: No, the plan was NOT

created pursuant to the Taft-Hartley Act.o Please confirm the Collective Bargaining Agreement was ratified prior to October 3, 2008. N/A

o Please provide the date for which the Collective Bargaining Agreement will expire. N/A

n order to complete your application, please provide this information by 5:00 pm, December 21, 2010. 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.

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

ennifer L. O. Sheer




[email protected]

01-492-4487

OTICE OF PRIVILEGE and CONFIDENTIALITY

he information contained in this electronic mail is privileged and

onfidential intended solely for the addressee. If the reader of this

message is not the intended recipient, you are hereby notified that

ny dissemination, distribution, or reproduction of this electronic

mail is strictly prohibited. If you have received this electronic mail

error, please contact Ulster-Greene ARC at 845-331-4300 ext.275

nd delete and destroy the original electronic mail and all copies.

hank you.

UlsterGreene:000006


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ANNUAL LIMIT WAIVER APPLICATION

Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Appl ican t

(Plan/ Policy

Situs) City

App licant

(Plan/

Policy

Situs)

State

Plan/ Policy

Effective Date

(mm/dd/yyyy)

Contact

Name

Street

Addr ess City State Zip Code

Phone

Number

(including

area code)

Email

Address

Type

Cover

(e.g., L

Benefit,

Rx only,

Applicant

ABC Plan 1 Washington DC 01/01/2011 J ane Doe

100 ABC

Drive Washington DC 20201

1-800-ABC-

1234

abc@abchea

lthplan.com Limited

UlsterGreene ARC

StandaloneHRA Kingston NY 01/01/2011

J ohnMcHugh

471 AlbanyAve Kingston NY 12401

1-845-331-4300

[email protected] HR

PRA Disclosure Statement

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


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Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Applicant

ABC Plan 1

Hospitalization Laboratory Pediatric

Maternity/

Newborn

Mental Health/

Substance

Abuse

Rehabilitative/

Devices

Preventive/

Wellness Prescription

Current Essential Benefits Annual Lim its (Annual Limi t for Each Essential Benefit)

UlsterGreene ARC

StandaloneHRA


According to the Paperworkinformation collection is 093search existing data resourcimproving this form, please


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Annual

Limit Waiver

Request

App licant

Name

Policy Name

(use a new

row for each

policy

application)

Applicant

ABC Plan 1

Individual/ Employee

Tier*

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Employer

contribution

(if applicable) Total

Employee

contribution

(if applicable)

Empl

contrib

(if appl

Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800

Current Monthly Premium Rates or

Premium Equivalent Rates (in dollars)*:

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver

Granted (in dollars)*

Projected Rate Increa

from compliance wit

Limit Restriction (in

Premium by

UlsterGreene ARC

StandaloneHRA


According to the Paperworkinformation collection is 093search existing data resourcimproving this form, please

Employee +Family

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


10/14


rom: Sheer, Jennifer (HHS/OCIIO)

ent: Thursday, December 23, 2010 11:41 AM

o: 'John McHugh'

ubject: Ulster Greene ARC Standalone HRA Annual Limit Waiver Application



Dear Applicant:

hank you for your information. Your application is now complete and you should receive a determination of yourpplication within 30 days.

hank you.

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

ennifer L. O. Sheer




[email protected]

01-492-4487

UlsterGreene:000010


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

rom: Habit, Sandra (HHS/OCIIO)ent: Thursday, December 30, 2010 6:00 PM

To: '[email protected]'ubject: Ulster Greene ARC Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdf

ood Afternoon,

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

ection 2711 for Ulster Greene ARC.HHS has reviewed your application and made its determination. Pleas

ee the attached letter.

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

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

incerely,

andy Habit

epartment of Health and Human Services


01-492-4175

[email protected]

NFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publiclysclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distribu

r copied to persons not authorized to receive the information. Unauthorized disclosures may result in prosecution to the full e

f the law.

UlsterGreene:000011


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

rom: Botwinick, Alexandra (HHS/OCIIO)ent: Wednesday, January 12, 2011 11:32 AM

To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Ulster Greene ARC Waiver of the Annual Limits Requirements of PHS Act Section 2711

mportance: High

Attachments: Updated Jan 1 Approval Letter .pdfood Morning,

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

ection 2711 for Ulster Greene ARC. HHS has reviewed your application and made its determination. Pleas

ee the attached letter.

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

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

incerely,

Alexandra Botwinick

ffice of Oversight

HHS/[email protected]

UlsterGreene:000012


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UlsterGreene:000013


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UlsterGreene:000014

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