Service Employees 32BJ North - Redacted Bates HW

7/27/2019 Service Employees 32BJ North - Redacted Bates HW

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From: Gabriele Schroeder [[email protected]]

Sent: Wednesday, December 01, 2010 5:17 PM

To: HHS HealthInsurance (HHS); OCIIO Oversight

Subject: Waiver

Attachments: NHBF Waiver Application 2010 12-01 with SPD.pdf

Follow Up Flag: Follow up

Flag Status: Flagged

Service Employees 32BJ North Health Benefit Plan Application for Waiver of Annual Limit Requirement of the Public Health

Service Act Section 2711

Gabriele Schroeder

Executive Assistant to Susan Cowell

Service Employees 32BJ North Health Benefit Fund

101 Avenue of the Americas

New York, NY 10013

Tel: (212) 388-3534

Fax: (212)388-2185

E-mail: [email protected]

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


2/20

S e r v i c e E m p l o y e e s 3 2 B J N o r t hH e a l t h B e n e f i t F u n d T R U 5 T E E S

K y l e B r a g g , C h a i r m a nH u g u e n o t S t r e e t , N e w R o c h e l l e , 1 0 8 0 1 - 5 2 1 0 E u g e n e s . R e f e m a n , 5 r e r a / yR i c h a r d W . B e r g e r

( 9 1 4 ) 6 3 7 - 7 0 0 0 F A X ( 9 1 4 ) 6 3 7 - 2 1 3 8 J u d i t h P a d o w

D e c e m b e r 1 , 2 0 1 0

B y E l e c t r o n i c M a i l

D e p a r t m e n t H e a l t h H u m a n S e r v i c e sO f f i c e C o n s u m e r I n f o r m a t i o n I n s u r a n c e O v e r s i g h t

O f f i c e O v e r s i g h t , R o o m 7 3 7 - F - 0 4A t t e n t i o n : J a m e s M a y h e wI n d e p e n d e n c e A v e n u e , S . W .

W a s h i n g t o n , D C 2 0 2 0 1R e : S e r v i c e E m p l o y e e s 3 2 B J N o r t h H e a l t h B e n e f i t P l a n - A p p l i c a t i o n W a i v e r

A n n u a l L i m i t R e q u i r e m e n t P u b l i c H e a l t h S e r v i c e A c t - S e c t i o n 2 7 1 1

D e a r M a y h e w :

O n b e h a l f S e r v i c e E m p l o y e e s 3 2 B J N o r t h H e a l t h B e n e f i t F u n d ' s ( " F u n d " ) B o a r dT r u s t e e s , w e r e s p e c t f u l l y r e q u e s t w a i v e r o f a n n u a l l i m i t r e q u i r e m e n t u n d e r

S e c t i o n 2 7 1 1 o f P u b l i c H e a l t h S e r v i c e A c t ( " P H S A " ) , a d d e d b y P a t i e n tP r o t e c t i o n A f f o r d a b l e C a r e A c t 2 0 1 0 ( " A f f o r d a b l e C a r e A c t " ) , e f f e c t i v e

p l a n y e a r b e g i n n i n g J a n u a r y 2 0 1 1 .

T e r m s P l a n

T h e F u n d c o l l e c t i v e l y b a r g a i n e d h e a l t h a n d w e l f a r e p l a n t h a t o f f e r s m e d i c a l , d e n t a l ,



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b e n e f i t s c o v e r e d p e r s o n s d e f r a y i n g r e a s o n a b l e a d m i n i s t r a t i v e e x p e n s e s . a s s e t sr e s e r v e s a r e h e l d t m s t i n v e s t e d b y B o a r d T r u s t e e s p u r s u a n t f i d u c i a r y

s t a n d a r d s r e q u i r e d f e d e r a l l a w . S i g n i f i c a n t l y , a s s e t s T r u s t f o r m s o l eb a s i s b e n e f i t s . C o l l e c t i v e b a r g a i n i n g a g r e e m e n t s m a i n t a i n i n g P l a n p r o v i d e

f i x e d c o n t r i b u t i o n s r a t e s , m a n y w h i c h d o n o t e x p i r e d u r i n g 2 0 1 1 . t h e r e a r ei n s u f f i c i e n t a s s e t s t r u s t , e m p l o y e r s n o t o b l i g a t e d m a k e s h o r t f a l lT r u s t e e s w o u l d f a c e d w i t h h a v i n g r e s t r i c t e l i g i b i l i t y a n d / o r m a k e o t h e r b e n e f i tm o d i f i c a t i o n s t h e P l a n .

A s N o v e m b e r 2 0 1 0 , P l a n c o v e r e d a p p r o x i m a t e l y p e r s o n s ( p a r t i c i p a n t s d e p e n d e n t s ) . S i n c e F u n d c u r r e n t l y o f f e r s o n l y p r o g r a m

b e n e f i t s , w a i v e r b e i n g r e q u e s t e d c o v e r s i n d i v i d u a l s e n r o l l e d t h e P l a n .

A n n u a l L i m i t s

P l a n c u r r e n t l y i m p o s e s l i m i t c a l e n d a r y e a r m e d i c a l h o s p i t a lb e n e f i t s . I n a d d i t i o n , t h e P l a n c o n t a i n s s o m e a n n u a l d o l l a r l i m i t s s p e c i f i c b e n e f i t s . T o

t h e e x t e n t t h a t s u c h a n n u a l l i m i t s p r o h i b i t e d b y a p p l y " e s s e n t i a l h e a l t hb e n e f i t s " d e f i n e d S e c t i o n 1 3 0 2 ( b ) A f f o r d a b l e C a r e A c t , F u n d r e q u e s t s

w a i v e r w e l l a s t h e s p e c i f i c a n n u a l m a x i m u m s d e s c r i b e d b e l o w :

A n n u a l m a x i m u m a l l e r g y t e s t i n g / t r e a t m e n t ;A n n u a l m a x i m u m d e r m a t o l o g y c a r e , e x c l u d i n g s k i n c a n c e rt r e a t m e n t ;A n n u a l m a x i m u m p r e s c r i p t i o n n u t r i t i o n a l s u p p l e m e n t s ;A n n u a l m a x i m u m o u t - o f - n e t w o r k v i s i o n s e r v i c e s t o w a r d s

e x a m , $ t o w a r d s f r a m e s a n d t o w a r d s l e n s e s .

C o m p l i a n c e I m p l i c a t i o n sT h e F u n d ' s B o a r d T r u s t e e s b e l i e v e s t h a t t h e r e a r e i n c r e a s e s e m p l o y e r



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5/20

From: Andrews, Jane (HHS/OCIIO)Sent: Saturday, December 18, 2010 4:58 PMTo: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)Subject: Your application for a waiver of annual limits requirements

Attachments: Waiver Application Form.xlsThank you for your application for the Waiver of the Annual Limits Requirements of the Public Health Service Act(PHS Act) Section 2711. In order to expedite your application, please provide the following information:

I. Please complete the entire annual limits spreadsheet, [attached to the email] [and available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html]. Please return the completed spreadsheetto this email address as an attachment. We will only be able to process spreadsheets that are fully complete

(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain toyour 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, if you did not include the following information in your application and is applicable, pleaseprovide the following information:

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

grandfathering provisions, pursuant to 45 CFR 147.140?

Confirm whether the plan was created pursuant to the Taft-Hartley Act. If is is, please provide the date the

collective bargaining agreement will expire.

Confirm that your plan is either self-insured or fully insured.

If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance,please submit that with the spreadsheet as a separate attachment.



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From: Gabriele Schroeder [[email protected]]Sent: Tuesday, December 21, 2010 3:15 PMTo: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO); Susan Cowell; 'Howard M. Bard'Subject: RE: Your application for a waiver of annual limits requirements

Attachments: 1-332329-4203_01_Revised_Annual_Waiver_Spreadsheet.xls; 1-332711-SEIU_32BJ_North_Health_Benefit_Fund_Annual_Limit_Waiver_Attachment.pdf; NHBF Waiver Attestation 2010 12-01.pdfOn behalf of the trustees of the Service Employees 32BJ North Health Benefit Fund and Susan Cowell, please note the

following:

I. Completed spreadsheet is attached.

II. Please see our answers below:

Thank you,

Gabriele Schroeder

Executive Assistant to Susan Cowell, Executive Director



New York, NY 10013

Tel: (212) 388-3534

Fax: (212)388-2185

E-mail: [email protected]

From: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]Sent: Saturday, December 18, 2010 4:58 PMTo: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)



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information regarding the staggered expiration dates of the collective bargaining agreements.

Confirm that your plan is either self-insured or fully insured. SELF-INSURED

If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance,

please submit that with the spreadsheet as a separate attachment. Attestation was submitted with application.We have attached a copy to this e-mail.

In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once thisinformation is received and the application is complete, it will be processed by the Department of Health and HumanServices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision.

Thank you and feel free to contact me with questions.

Jane W. Andrews

OCIIO

7501 Wisconsin Ave

Bethesda, MD 20814

301-492-4122 (desk)

202-536-6779 (Blackberry)

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 governmentuse only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.

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



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Annual

Limit Waiver

Request

App lic antName

Policy Name

(use a new

row for each

policyapplication)

Applicant

(Plan/ PolicySitus) City

App lic ant

(Plan/

Policy

Situs)State

Plan/ Policy

Effective Date(mm/dd/yyyy)

ContactName

StreetAddress City State Zip Code

Phone

Number

(includingarea code)

EmailAddress

Type of

Coverage

(e.g., Limited

Benefit, HRA,Rx only, Other)

Service

Employees

32BJ North

Service

Employees

32BJ North 101 Avenue scowell@32Health

Benefit Fund

Health Benefit

Fund New Rochelle NY 01/01/2011

Susan

Cowell

of the

Americas New York NY 10013

(212) 388-

2104

BJ FUNDS.C

OM Other

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless itdisplays a valid OMB control number. The valid OMB cinformation collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to

search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.



9/20

Annual

Limit Waiver

Request

App lic antName

Policy Name

(use a new

row for each

policyapplication)

Service

Employees

32BJ North

Service

Employees

32BJ North

Ambulator y Emergency Hosp italizat ion Laboratory Pediat ricMaternity/Newborn

Mental Health/

SubstanceAbuse

Rehabilitative/Devices

P

Current Essential Benefits Annual Limits (Annual Lim it fo r Each Essential Benefit)

Health

Benefit Fund

Health Benefit

Fund


According to the Paperworkinformation collection is 093

search existing data resourcimproving this form, please

None None None

None None None



10/20

Annual

Limit Waiver

Request

App lic antName

Policy Name

(use a new

row for each

policyapplication)

Service

Employees

32BJ North

Service

Employees

32BJ North

Coinsura

nce (if

applicable)

Copay (if

applicable)

Coinsuran

ce (ifapplicable)

Individual/ EmployeeTier*

Employee

contribution(if applicable)

Employer

contribution(if applicable) Total

Employee

contribution(if applicable)

Employer

contribution(if applicable) Total

Current Monthly Premium Rates or

Premium Equivalent Rates (in dol lars)*:

Rx

Copay/Coninsurance

Renewal Monthly Premium Rates or

Premium Equivalent Rates if Waiver Gran

(in dollars)*

cy Room

insurance

Health

Benefit Fund

Health Benefit

Fund




None

* When completing the columns requesting premium rate information, please expres

premiums are a range based on years of service or age) and by tier (Employee, Emetc.) as applicable. If you are an issuer, please provide the premium amount in the c



11/20

Annual

Limit Waiver

Request

App lic antName

Policy Name

(use a new

row for each

policyapplication)

Service

Employees

32BJ North

Service

Employees

32BJ North

Title of Individual

ProvidingAtt estat ion

Kyle Bragg, Chairman

Eugene Reisman,Health

Benefit Fund

Health Benefit

Fund




Secretary

Board of Trustees



12/20

Service Employees 32BJ North Health Benefit FundWaiver of Annual Limits Requirements

Attachment to Application

Column AR and AT - Projected Rate Increase that would result from compliance

with the $750,000 Annual Limit Restriction

The Service Employees 32BJ North Health Benefit Fund ("Fund") is amultiemployer Taft-Hartley health and welfare fund. All medical benefits under theFund are self insured and funded solely by contributions by contributing employers

pursuant to collective bargaining agreements between the participating employers andService Employees International Union 32 BJ. These collective bargaining agreementshave staggered expiration dates ranging from December 2010 through April 2013although the collective bargaining agreements covering approximately percent of theFund's participants expire between March 2011 and April 2013. Since the Employercontribution rates that fund the Fund are fixed under the collective bargainingagreements, the Fund cannot at this point determine how it would cover the additionalcosts of complying with the annual limits prohibition if the waiver is not granted and ifemployer contribution increases cannot be obtained.

Nevertheless, for the purposes of completing this spreadsheet, the Fund hascalculated how much the amount of the employees monthly contributions wouldincrease, if the costs were paid in that way. As the chart indicates employeecontributions would increase substantially from $ annually to $ annually.

Column AV - Decrease in Access to Benefits that would Result from compliancewith $750,000 Annual Limit Restriction

As a multiemployer Taft Hartley Plan with contribution rates set in collective



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waiver is not granted and if employer contribution increases cannot be obtained. Pleaselet us know if you need specific calculations.



14/20

From: Andrews, Jane (HHS/OCIIO)Sent: Thursday, December 23, 2010 8:21 AMTo: 'Gabriele Schroeder'Cc: Habit, Sandra (HHS/OCIIO); 'Susan Cowell'; 'Howard M. Bard'Subject: RE: Your application for a waiver of annual limits requirements

Thank you. Your application is complete.

Jane W. Andrews

OCIIO

7501 Wisconsin Ave

Bethesda, MD 20814

301-492-4122 (desk)

202-536-6779 (Blackberry)

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 governmentuse only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.

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

From: Gabriele Schroeder [mailto:[email protected]]Sent: Tuesday, December 21, 2010 3:15 PMTo: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO); Susan Cowell; 'Howard M. Bard'Subject: RE: Your application for a waiver of annual limits requirements

On behalf of the trustees of the Service Employees 32BJ North Health Benefit Fund and Susan Cowell, please note the

following:

I. Completed spreadsheet is attached.

II. Please see our answers below:

Thank you,



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I. Please complete the entire annual limits spreadsheet, [attached to the email] [and available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html]. Please return the completed spreadsheetto this email address as an attachment. We will only be able to process spreadsheets that are fully complete(i.e., every cell should contain the information requested). If a cell on the spreadsheet does not pertain toyour 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, if you did not include the following information in your application and is applicable, pleaseprovide 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

Confirm whether the plan was created pursuant to the Taft-Hartley Act. If is is, please provide the date thecollective bargaining agreement will expire.YES, This is a multiemployer plan. Please see the attachment for

information regarding the staggered expiration dates of the collective bargaining agreements.

Confirm that your plan is either self-insured or fully insured. SELF-INSURED

If you did not complete and submit a signed attestation in accordance with the September 3, 2010 guidance,

please submit that with the spreadsheet as a separate attachment. Attestation was submitted with application.

We have attached a copy to this e-mail.

In order to complete your application, please provide this information by 5:00 pm, December 21, 2010. Once thisinformation is received and the application is complete, it will be processed by the Department of Health and HumanServices (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision.

Thank you and feel free to contact me with questions.

Jane W. Andrews



16/20

From: Botwinick, Alexandra (HHS/OCIIO)Sent: Wednesday, December 29, 2010 4:13 PMTo: [email protected]: Service Employees 32BJ North Health Benefit Fund Waiver of the Annual Limits Requirements 12-29-2010

Importance: High

Follow Up Flag: Follow upFlag Status: Green

Attachments: Updated Jan 1 Approval Letter .pdf

Good Afternoon,Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS ActSection 2711 for Service Employees 32BJ North Health Benefit Fund.HHS has reviewed your application andmade its determination. Please see the attached letter.Please confirm receipt of this letter by replying to this e-mail.Please let me know if I can be of further assistance.Sincerely,Alexandra BotwinickOffice of Oversight

HHS/[email protected]

mailto:[email protected]:[email protected]


17/20



18/20



19/20

From: Gabriele Schroeder [[email protected]] on behalf of Susan Cowell[[email protected]]Sent: Thursday, December 30, 2010 10:25 AMTo: Botwinick, Alexandra (HHS/OCIIO)Subject: RE: Service Employees 32BJ North Health Benefit Fund Waiver of the Annual Limits Requirements 12-29-

2010

Follow Up Flag: Follow upFlag Status: RedPlease be advised that Susan Cowell, Executive Director, has received the email below and determination letter.

Thank you,

Gabriele Schroeder

Executive Assistant to Susan Cowell



New York, NY 10013

Tel: (212) 388-3534

Fax: (212)388-2185E-mail: [email protected]

From: Botwinick, Alexandra (HHS/OCIIO) [mailto:[email protected]]Sent: Wednesday, December 29, 2010 4:13 PMTo: Susan CowellSubject: Service Employees 32BJ North Health Benefit Fund Waiver of the Annual Limits Requirements 12-29-2010Importance: High

Good Afternoon,

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



20/20

Pages 21 through 134 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption 4

Service 32BJN:000020


Documents

Service Employees 32BJ North - Redacted Bates HW