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///co-adshare/...aivers%20-%20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/WAIVER.htm[11/14/2011 11:02:0
rom: Russell Brown [[email protected]]ent: Tuesday, November 30, 2010 5:35 PM
To: HHS HealthInsurance (HHS)Cc: 'Bill Pohlman'; 'Jim Ringland'; 'Marty Joseph'ubject: WAIVER
Attachments: Signed Waiver Attestation.pdf; Waiver Annual Limits.pdfttached is an Annual Limits waiver application with supporting documentation. I apologize for the late timing in filing the reque
s this is a 1/1/2011 Plan. It took us longer to analyze the impact than expected. If there is additional information needed or
arifications on information submitted, I will be glad to assist.
hank you for your review
ussell Brown
irector Market Services
enefit Administrative Systems, LLC (Claim Administrator for Plan)
08-647-3417
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Page 8 redacted for the following reason:- - - - - - - - - - - - - - - - - - - - -(b)(4)
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Page 18 redacted for the following reason:- - - - - - - - - - - - - - - - - - - - -(b)(4)
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Page 19 redacted for the following reason:- - - - - - - - - - - - - - - - - - - - -(b)(4)
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///co-adshare/...OI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%2012.18.10.htm[11/14/2011 11:02
rom: Andrews, Jane (HHS/OCIIO)ent: Saturday, December 18, 2010 4:58 PM
To: Andrews, Jane (HHS/OCIIO)Cc: Habit, Sandra (HHS/OCIIO)
ubject: Your application for a waiver of annual limits requirements
Attachments: Waiver Application Form.xlshank 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 spreadshto 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, 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.
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 and feel free to contact me with questions.
ane W. Andrews
CIIO
501 Wisconsin Aveethesda, 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.
GLISTER:000021
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ANNUAL LIMIT WAIVER APPLICATION 2010
al
Waiverest
c ante
Policy Name
(use a newrow for each
policyapplication)
Applic ant
(Plan/ PolicySitus) City
Applic ant
(Plan/Policy
Situs)State
Plan/ Policy
Effective Date(mm/dd/yyyy)
ContactName
StreetAddress City State Zip Code
PhoneNumber
(includingarea code)
EmailAddres s
Type of
Coverage(e.g., Limited
Benefit, HRA,Rx only, Other)
Self-
Insured(Yes/No)
Individual orGroup Policy
TotalNumber of
IndividualsCovered by
Policy(include all
dependentscovered)
Current
Plan OverallAnnual
Limit (indollars)
plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe
100 ABCDrive Washington DC 20201
1-800-ABC-1234
[email protected] Limited Benefit Yes Group 4,000 $100,000
plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe
100 ABCDrive Washington DC 20202
1-800-ABC-1234
[email protected] Limited Benefit Yes Group 2,500 $100,000
Disclosure Statement
ording to the Paperwork Reductio n Act of 1995, no per sons are required to respond to a collection of infor mation unless it displays a valid OMB control number. The valid OMB control number f or 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 in formation 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.
GLISTER:000022
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected] -
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ANNUAL LIMIT WAIVER APPLICATION 2010
mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn
Mental Health/
SubstanceAbuse
Rehabilitative/Devices
Preventive/Wel ln es s Pr es cr ip ti on
PlanDeductible
Copay (if
applicable)
Coinsuranc
e (ifapplicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
None None None None None None None None None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00
None None None None None None None None None $3,000.00 $1,000.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00
Office VisitCopays/Coinsurance
Hospital InpatientCopay/Coinsurance
Emergency RoomCopay/CoinsuranceCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit) Copay/Co
GLISTER:000023
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ANNUAL LIMIT WAIVER APPLICATION 2010
suran
e (ifcable)
Individual/ EmployeeTier*
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Employee
contribution(if applicable)
Employer
contribution( if ap pl ic ab le) To tal
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Projected Rate Increasethat would result from
compliance with $750,000
Annual L imit Rest rict ion(in doll ars)(Average
Premium by Individual)(Difference of Column AT
and AQ divided byColumn AQ)
Access t oBenefits that
would resultfrom
compliancewith $750,000Annual L imit
Restriction(describe
briefly in cellor in a
PlanAdmini strator/ CEO
of HealthInsuranc
e IssuerName
Title of Individual
ProvidingAttest ation
one Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800.00 $925.00 21.71% None Jane Doe Plan Administrator
one Employee + Family $105.00 $1,100.00 $1,205.00 $115.00 $1,150.00 $1,265.00 $150.00 $1,400.00 $1,550.00 22.53% None Jane Doe Plan Administrator
Projected Rate Increase that would result
from c ompliance with $750,000 Annual LimitRestriction (in do llars) (Average Premium by
Individual)*Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:rance
Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted
(in dollars)*
* 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).
GLISTER:000024
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///co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:2
rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 10, 2011 10:49 AM
To: 'Russell Brown'Cc: Habit, Sandra (HHS/OCIIO)
ubject: RE: Your application for a waiver of annual limits requirementshank you. The application for Gilster-Mary Lee Corporation Group is now complete. The applicant should be hearing soon w
etermination.
ane W. Andrews
CIIO501 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.
rom: Russell Brown [mailto:[email protected]]ent: Monday, January 10, 2011 8:51 AMo: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limits requirements
he Plan is not Taft Hartley and it does not plan on maintaining Grandfather status
rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Friday, January 07, 2011 4:36 PMo: 'Russell Brown'ubject: RE: Your application for a waiver of annual limits requirements
have incorporated the spreadsheet and I have the data I need for that. However, do you have answer to the questions below
bout whether you are a Taft Hartley plan, and if so when does the cba expire, and your compliance with the grandfather
egulation.
hanks.
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.
rom: Russell Brown [mailto:[email protected]]ent: Tuesday, December 21, 2010 3:35 PMo: Andrews, Jane (HHS/OCIIO)ubject: RE: Your application for a waiver of annual limits requirements
GLISTER:000025
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///co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:2
ttached is the waiver application and a copy of the attestation submitted in late November 2010.
hank you for your assistance
ussell Brown
rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Saturday, December 18, 2010 3:58 PMo: Andrews, Jane (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: Your application for a waiver of annual limits requirements
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 the email] [and available at:http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html]. Please return the completed spreadshto 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, 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.
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 and feel free to contact me with questions.
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
GLISTER:000026
-
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///co-adshare/...20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/completion%201.10.11.htm[11/14/2011 11:02:2
Unauthorized disclosure may result in prosecution to the full extent of the law.
GLISTER:000027
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///co-adshare/...cessing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%20response%201.4.11.htm[11/14/2011 11:02
rom: Andrews, Jane (HHS/OCIIO)ent: Monday, January 10, 2011 10:59 AM
To: Habit, Sandra (HHS/OCIIO)ubject: FW: Your application for a waiver of annual limits requirements
Attachments: Waiver Application Form.xls; signed waiver attestation 2.pdfpologize if this is a dupe, but I dont see that I forwarded it to be file in Gilster-Mary Lee Corpor file.
ane W. Andrews
CIIO501 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.
rom: Russell Brown [mailto:[email protected]]ent: Tuesday, January 04, 2011 3:46 PMo: Andrews, Jane (HHS/OCIIO)ubject: FW: Your application for a waiver of annual limits requirements
rom: Russell Brown [mailto:[email protected]]ent: Tuesday, December 21, 2010 2:35 PMo: 'Andrews, Jane (HHS/OCIIO)'ubject: RE: Your application for a waiver of annual limits requirements
ttached is the waiver application and a copy of the attestation submitted in late November 2010.
hank you for your assistance
ussell Brown
rom: Andrews, Jane (HHS/OCIIO) [mailto:[email protected]]ent: Saturday, December 18, 2010 3:58 PMo: Andrews, Jane (HHS/OCIIO)c: Habit, Sandra (HHS/OCIIO)ubject: Your application for a waiver of annual limits requirements
hank 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 spreadshto 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, if you did not include the following information in your application and is applicable, pleaseprovide the following information:
GLISTER:000028
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///co-adshare/...cessing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Request%20for%20info%20response%201.4.11.htm[11/14/2011 11:02
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.
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 and feel free to contact me with questions.
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.
GLISTER:000029
-
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ANNUAL LIMIT WAIVER APPLICATION 2010
al
Waiverest
c ante
Policy Name
(use a newrow for each
policyapplication)
Applic ant
(Plan/ PolicySitus) City
Applic ant
(Plan/Policy
Situs)State
Plan/ Policy
Effective Date(mm/dd/yyyy)
ContactName
StreetAddress City State Zip Code
PhoneNumber
(includingarea code)
EmailAddres s
Type of
Coverage(e.g., Limited
Benefit, HRA,Rx only, Other)
Self-
Insured(Yes/No)
Individual orGroup Policy
TotalNumber of
IndividualsCovered by
Policy(include all
dependentscovered)
Current
Plan OverallAnnual
Limit (indollars)
plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe
100 ABCDrive Washington DC 20201
1-800-ABC-1234
[email protected] Limited Benefit Yes Group 4,000 $100,000
plicantABC Plan 1 Washington DC 01/01/2011 Jane Doe
100 ABCDrive Washington DC 20202
1-800-ABC-1234
[email protected] Limited Benefit Yes Group 2,500 $100,000
Lee Corpporation Grou Chester IL 01/01/2011 Karen Lowry 1037 State St Chester IL 62233 618-826-2361 gilstermaryle other Yes Group Lee Corpporation Grou Chester IL 01/01/2011 Karen Lowry 1037 State St Chester IL 62233 618-826-2361 gilstermaryle other Yes Group
Disclosure Statement
ording to the Paperwork Reductio n Act of 1995, no per sons are required to respond to a collection of infor mation unless it displays a valid OMB control number. The valid OMB control number f or 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 in formation 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.
GLISTER:000030
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected] -
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ANNUAL LIMIT WAIVER APPLICATION 2010
mbulat ory Emergency Hospit alization Laborat ory PediatricMaternity/Newborn
Mental Health/
SubstanceAbuse
Rehabilitative/Devices
Preventive/Wel ln es s Pr es cr ip ti on
PlanDeductible
Copay (if
applicable)
Coinsuranc
e (ifapplicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
Coinsurance (if
applicable)
Copay (if
applicable)
None None None None None None None None None $3,000.00 $500.00 $15.00 50.00% $100.00 50.00% $100.00 50.00% $10.00
Office VisitCopays/Coinsurance
Hospital InpatientCopay/Coinsurance
Emergency RoomCopay/CoinsuranceCurrent Essential Benefits Annual Limits (Annual Limit f or Each Essential Benefit) Copay/Co
GLISTER:000031
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ANNUAL LIMIT WAIVER APPLICATION 2010
suran
e (ifcable)
Individual/ EmployeeTier*
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Employee
contribution(if applicable)
Employer
contribution( if ap pl ic ab le) To tal
Employee
contribution(if applicable)
Employer
contribution(i f ap pl ic ab le) To tal
Projected Rate Increasethat would result from
compliance with $750,000
Annual L imit Rest rict ion(in doll ars)(Average
Premium by Individual)(Difference of Column AT
and AQ divided byColumn AQ)
Access t oBenefits that
would resultfrom
compliancewith $750,000Annual L imit
Restriction(describe
briefly in cellor in a
PlanAdmini strator/ CEO
of HealthInsuranc
e IssuerName
Title of Individual
ProvidingAttest ation
one Employee $100.00 $600.00 $700.00 $110.00 $650.00 $760.00 $125.00 $800.00 $925.00 21.71% None Jane Doe Plan Administrator
None Jane Doe Plan Admin is trator
None chael Wed Plan Administrator
None chael Wed Plan Administrator
Projected Rate Increase that would result
from c ompliance with $750,000 Annual LimitRestriction (in do llars) (Average Premium by
Individual)*Current Monthly Premium Rates or
Premium Equivalent Rates (in dollars)*:rance
Renewal Monthly Premium Rates orPremium Equivalent Rates if Waiver Granted
(in dollars)*
* 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).
GLISTER:000032
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///co-adshare/...-%20Torres/DFOI%20Processing%20Team/Brandon/Gilster-Mary%20Lee%20Corporation/Approval%201.31.11.htm[11/14/2011 11:02
rom: Botwinick, Alexandra (HHS/OCIIO)ent: Monday, January 31, 2011 9:26 AM
To: '[email protected]'Cc: Habit, Sandra (HHS/OCIIO)ubject: Gilster-Mary Lee Corporation Waiver of the Annual Limits Requirements 1-31-2011
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 forGilster-Mary Lee Corporation, Group Health Plan.HHS has reviewed your application andmade its determination. Please see 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.
Alexandra Botwinick
ffice of Oversight
GLISTER:000034
mailto:[email protected]:[email protected] -
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GLISTER:000035
-
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