Arc Onondaga-Redacted HW
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Transcript of Arc Onondaga-Redacted HW
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Pages 3 through 18 redacted for the following reasons:- - - - - - - - - - - - - - - - - - - - - - - - - - - -Exemption (b)(4)
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ANNUAL LIMIT WAIVER APPLICATION 2010
alWaiver
estc ante
Policy Name(use a new
row for eachpolicyapplication)
Applic ant(Plan/ PolicySitus) City
Applic ant(Plan/
PolicySitus)State
Plan/ PolicyEffective Date
(mm/dd/yyyy)
Contact
Name
Street
Address City State Zip Code
Phone
Number(includingarea code)
EmailAddress
Type ofCoverage
(e.g., LimitedBenefit, HRA,
Rx only, Other)
Self-Insured(Yes/No)
Individual orGroup Policy
TotalNumber ofIndividuals
Covered byPolicy
(include alldependents
covered)
CurrentPlan Overall
AnnualLimit (in
dollars)
plicantHRA Plan A Bethesda MD 01/01/2011 John Doe
100 HRADrive Bethesda MD 20814
1-800-HRA-1234
[email protected] HRA Yes Group 50 $3,500
Disclosure Statement
ording to the Paperwork Reductio n Act of 1995, no person s are required to respond to a collection of inform ation unless it displays a valid OMB control number. The valid OMB control number fo r thismation collection is 0938-1105. The time required to complete this information collection is estimated to average ( 8 hours) or ( 240 minutes) per response, including the time to review instructions,ch existing data resources, gather the data needed, and complete and review the inf ormation collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions foroving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
ARC ONONDAGA:000008
mailto:[email protected]:[email protected]:[email protected]:[email protected] -
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ANNUAL LIMIT WAIVER APPLICATION 2010
mbulat ory Emergency Hospit alization Laborat ory Pediatric
Maternity/
Newborn
Mental Health/Substance
Abuse
Rehabilitative/
Devices
Preventive/
Wel ln es s Pr es cr ip ti on
Plan
Deductible
Copay (ifapplicabl
e)
Coinsurance (if
applicable)
Copay (ifapplicabl
e)
Coinsura
nce (ifapplicabl
e)
Copay (ifapplicabl
e)
Coinsura
nce (ifapplicabl
e)
Copay (ifapplicabl
e)
C
a
None None None None None None None None None None $0.00 $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.00
Current Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit)
Rx
Copay/Con
Office Visit
Copays/Coinsurance
Hospital Inpatient
Copay/Coinsurance
Emergency Room
Copay/Coinsurance
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ANNUAL LIMIT WAIVER APPLICATION 2010
idual/ EmployeeEmployee
contribution
(if applicable)
Employercontribution
(i f ap pl ic ab le) To tal
Employeecontribution
(if applicable)
Employercontribution
(i f ap pl ic ab le) To tal
Employeecontribution
(if applicable)
Employercontribution
( if ap pl ic ab le) To tal
Projected Rate Increase
that would result fromcompliance with $750,000Annual L imit Rest rict ion
(in do llars)(AveragePremium by Individual)
(Difference of Column ATand AQ divided by
Column AQ)
Access t o
Benefits thatwould result
fromcompliance
with $750,000
Annual L imitRestriction
(describebriefly in cell
or in a
PlanAdmini str
ator/ CEOof Health
Insurance IssuerName
Title of IndividualProviding
Attest ation
Employee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00"HRA plan will
terminate." John Doe Plan Administrator
Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:
Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted
(in dollars)*
Projected Rate Increase that would resultfrom compli ance with $750,000 Annual LimitRestriction (in d ollars) (Average Premium by
Individual)*
* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (ifpremiums 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).
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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Waiver.txt[10/31/2011 11:42:06 PM]
rom: Jessica Seals [[email protected]]ent: Wednesday, December 01, 2010 3:11 PMo: HHS HealthInsurance (HHS)ubject: Waiver
Attachments: WLBRHRBH20020101201150500.pdf
ollow Up Flag: Follow uplag Status: Completed
Waiver request from Arc of Onondaganclosed please find:) Written request for Waiver) Summary Plan Description) Summary of Material Modification
-----------------------------essica Seals, Director of Human Resources: [email protected] | V: (315) 476-7441x 1173 | F: (315) 472-0873 |
W: www.arcon.org
Arc of Onondaga00 South Wilbur Avenueyracuse, New York 13204
Mission Statement: Arc of Onondaga assists individuals with developmentalisabilities achieve their fullest potential.
his message is intended for the sole use of the
ndividual and entity to which it is addressed
nd may contain information that is privileged,
onfidential, and exempt from disclosure under
pplicable law.
f you are not the recipient, nor authorized to
eceive for recipient, you are hereby notified
hat you may not use, copy, disclose or distribute
o anyone the message or any information
ontained in the message.
f you have received this message in error
lease immediately advise the sender by
ARC ONONDAGA:000011
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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Waiver.txt[10/31/2011 11:42:06 PM]
eply email and delete the message.
hank you.
Arc of Onondaga is an Equal Opportunity Employer.
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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Approval%201.12.11.htm[10/31/2011 11:42:06 PM]
rom: Botwinick, Alexandra (HHS/OCIIO)ent: Wednesday, January 12, 2011 12:02 PMTo: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Arc of Onondaga 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 Arc of Onondaga. HHS has reviewed your application and made its determination. Please
he 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
ARC ONONDAGA:000013
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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Approval%20receipt%201.12.11.htm[10/31/2011 11:42:07 PM]
rom: Jessica [[email protected]]ent: Wednesday, January 12, 2011 1:07 PM
To: Botwinick, Alexandra (HHS/OCIIO); Habit, Sandra (HHS/OCIIO)Cc: [email protected]; [email protected]: Arc of Onondaga Waiver response
Ms. Botwinick:
hank you for your time. We are in receipt of the approval letter sent from HHS regarding our waiver. My direct response to y
mail was bounced back by your server.
you need any further information, please do not hesitate to contact us. We thank you for your assistance
incerely,
essica Seals
----------------------------
essica Seals, Director of Human Resources
:[email protected] | V: (315) 476-7441x 1173 | F: (315) 472-0873 | W: www.arcon.org
rc of Onondaga
00 South Wilbur Avenueyracuse, New York 13204
Mission Statement: Arc of Onondaga assists individuals with developmental disabilities achieve their fullest potential.
ARC ONONDAGA:000014
mailto:[email protected]:[email protected]://www.arcon.org/http://www.arcon.org/mailto:[email protected] -
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//C|/Documents%20and%20Settings/ig20/Desktop/Arc%20of%20Onondaga/Reqeust%20for%20info%2012.22.10.htm[10/31/2011 11:42:07 PM]
rom: Andrews, Jane (HHS/OCIIO)ent: Wednesday, December 22, 2010 1:09 PM
To: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)
ubject: Your application for a waiver of Annual Limits for an HRA
Attachments: HRAspreadsheet.xlsn order to expedite your application, please provide the following information:
lease complete the entire annual limits spreadsheet, (attached to the email). Please return the completed spreadsheo this email address as an attachment. We will only be able to process spreadsheets that are fully complete (i.e., evell should contain the information requested). If a cell on the spreadsheet does not pertain to your plan, please wrNone, and/or provide an explanation regarding why you are unable to complete that particular cell in a separateocument. An example of how to complete the spreadsheet is provided in the first row.
n addition, if you did not submit a signed attestation from the plan administrator, please follow the instructions onttestations provided in the September 3, 2010 guidance, page 3, number 5, and have that scanned to this e-mailddress.
hank you.
ane W. Andrews
CIIO
501 Wisconsin Ave
ethesda, MD 20814
01-492-4122 (desk)
02-536-6779 (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 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.
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