Brevard Achievement Center - Redacted HWM

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From: Habit, Sandra (HHS/OCIIO) Sent: Thursday, December 16, 2010 4:07 PM To: '[email protected]' Subject: Waiver Application - Brevard Achievement Center Dayle, Thank 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, available at: http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html. Please return the completed spreadsheet to 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 to your plan, please write None, and/or provide an explanation regarding why you are unable to complete that particular cell in a separate document.

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

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Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 [email protected]

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II. In addition, please provide the following information: Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? Once this information is received and the application is complete, it will be processed by the Department of Health and Human Services (HHS). As stated in our September 3, 2010 Sub-Regulatory Guidance, HHS will issue a decision within 30 days of receiving a complete application. You will receive an e-mail from HHS notifying you of the waiver decision. Thank you, Sandy

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file:////co-adshare/...FOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20info%2012.16.10.htm[11/08/2011 11:19:46 AM]

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BREVARD:000070

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

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file:////co-adshare/...FOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20info%2012.27.10.htm[11/08/2011 11:19:53 AM]

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Mr. Olson, I sent you the spreadsheet on December 16, 2010 that would need to be completed in order to complete your application for Brevard Achievement Center, unfortunately, I have not heard back from you as of this time. If you have any questions please feel free to contact me. Sandy Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 [email protected]

From: Habit, Sandra (HHS/OCIIO) Sent: Monday, December 27, 2010 1:10 PM To: '[email protected]' Subject: Waiver Application - Brevard Achievement Center

BREVARD:000071

From: Dayle Olson [[email protected]] Sent: Monday, December 27, 2010 2:58 PM To: Habit, Sandra (HHS/OCIIO) Subject: Re: Waiver Application - Brevard Achievement Center Sandy Sorry about the delay -I have been away unexpected - but do return to work tomorrow. I will make it my priority in the morning Dayle Sent from my iPhone On Dec 27, 2010, at 1:10 PM, "Habit, Sandra (HHS/OCIIO)" <[email protected]> wrote:
Mr. Olson, I sent you the spreadsheet on December 16, 2010 that would need to be completed in order to complete your application for Brevard Achievement Center, unfortunately, I have not heard back from you as of this time. If you have any questions please feel free to contact me. Sandy Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 [email protected]

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

Total Control Panel

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Login High (60): Pass Medium (75): Pass Low (90): Pass

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file:////co-adshare/...on/Brevard%20Achievement%20Center/Request%20for%20info%20correspondence%2012.27.10.htm[11/08/2011 11:20:00 AM]

From: Dayle Olson [[email protected]] Sent: Tuesday, December 28, 2010 5:27 PM To: Habit, Sandra (HHS/OCIIO) Subject: Re: Waiver Application - Brevard Achievement Center Attachments: baccolorlogo.htm Sandra - -the spreadsheet for the Waiver for the Brevard Achievement Center is nearly complete. Our Benefits Coordinator has agreed to come in tomorrow to finish it for us (she is on Holiday leave). As soon as she finishes the report I will get it to you. Dayle Olson

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Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]

file:////co-adshare/...Processing%20Team/Brandon/Brevard%20Achievement%20Center/Correspondence%2012.28.10.htm[11/08/2011 11:20:07 AM]

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From: Habit, Sandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 10:08 AM To: 'Dayle Olson' Subject: RE: Waiver Application - Brevard Achievement Center
Dayle, Thank you. Sandy From: Dayle Olson [mailto:[email protected]] Sent: Tuesday, December 28, 2010 5:27 PM To: Habit, Sandra (HHS/OCIIO) Subject: Re: Waiver Application - Brevard Achievement Center

Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]

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Sandra - -the spreadsheet for the Waiver for the Brevard Achievement Center is nearly complete. Our Benefits Coordinator has agreed to come in tomorrow to finish it for us (she is on Holiday leave). As soon as she finishes the report I will get it to you. Dayle Olson

file:////co-adshare/...20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Correspondence%20response%2012.29.10.htm[11/08/2011 11:20:13 AM]

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From: Dayle Olson [[email protected]] Sent: Wednesday, December 29, 2010 1:47 PM To: Habit, Sandra (HHS/OCIIO) Cc: Tere Sulzbach Subject: Fwd: RE: Waiver Application - Brevard Achievement Center Attachments: BAC Waiver Application Form.xls; baccolorlogo.htm Sandra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know. Too much snow there??? Dayle Olson

>>> Tere Sulzbach 12/29/2010 1:11 PM >>> Hi Sandra, Attached please find the completed spreadsheet. Answers to questions: II.

* Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? YES Please let us know if you have any questions, Dayle

_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you. Tere Sulzbach Benefits & Compensation Administrator

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* Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. NO

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BREVARD:000075

Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]

file:////co-adshare/.../Brandon/Brevard%20Achievement%20Center/Request%20for%20info%20response%2012.29.10.htm[11/08/2011 11:20:19 AM]

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ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name

Policy Name (use a new row for each Applicant policy (Plan/ Policy application) Situs) City Brevard Achievement Brevard Center, Inc. Achievement Health & Center, Inc. Welfare Plan Rockledge

Applicant (Plan/ Policy Plan/ Policy Situs) Effective Date Contact State (mm/dd/yyyy) Name

Street Address

City

State

Phone Number (including Zip Code area code)

FL

06/01/2000

Teresa Sulzbach

1845 Cogswell Street

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Email Address tsulzbach@ba Limited Benefit Yes

Total Number of Individuals Covered by Type of Current Policy Coverage Plan Overall (include all (e.g., Limited SelfAnnual Benefit, HRA, Insured Individual or dependents Limit (in Rx only, Other) (Yes/No) Group Policy

Rockledge

FL

32955

321-6328610

(b)(4)

Group

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 valid OMB control number for this information 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, 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) or suggestions for improving 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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BREVARD:000076

ANNUAL LIMIT WAIVER APPLICATION 2010

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/ Newborn

Mental Health/ Substance Abuse

Rehabilitative/ Devices

(b)(4)

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Preventive/ Wellness Prescription

Current Essential Benefits Annual Limits (Annual Limit for Each Essential Benefit)

Office Visit Hospital Inpatient Emergency Room R Copays/Coinsurance Copay/Coinsurance Copay/Coinsurance Copay/Co

Coinsura Coinsura nce (if Copay (if nce (if Copay (if Copay (if Coinsuranc Copay (if Plan applicabl e (if applicabl applicabl applicabl applicabl applicabl e) e) e) e) Deductible e) applicable) e)

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ANNUAL LIMIT WAIVER APPLICATION 2010

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Rx ninsurance

Current Monthly Premium Rates or Premium Equivalent Rates (in dollars)*:

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

Coinsuran Employee Employer ce (if Individual/ Employee contribution contribution applicable) Tier* (if applicable) (if applicable)

Total

Employee Employer contribution contribution (if applicable) (if applicable)

Total

Employee Employer contribution contribution (if applicable) (if applicable)

Total

Decrease in Access to Benefits that Projected Rate Increase would result that would result from from compliance with $750,000 compliance Annual Limit Restriction with $750,000 (in dollars)(Average Annual Limit Premium by Individual) Restriction (Difference of Column AT (describe and AQ divided by briefly in cell Column AQ) or in a

Plan Administr ator/ CEO of Health Insuranc e Issuer Name

Title of Individual Providing Attestation

(b)(4)

Policy Terminated

Teresa Chris Caveness/TPA Sulzbach Plan Coordinator

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (if premiums 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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BREVARD:000078

From: Habit, Sandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 2:28 PM To: 'Dayle Olson' Cc: 'Tere Sulzbach' Subject: RE: RE: Waiver Application - Brevard Achievement Center
Dayle, Thank you so much for your response. I have one question for you, is the information only to be broken down into employee + family? There are no other tiers available, i.e. employee only, employee + spouse, etc? We were lucky this time around, the snow hit further east! Sandy From: Dayle Olson [mailto:[email protected]] Sent: Wednesday, December 29, 2010 1:47 PM To: Habit, Sandra (HHS/OCIIO) Cc: Tere Sulzbach Subject: Fwd: RE: Waiver Application - Brevard Achievement Center

Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]

>>> Tere Sulzbach 12/29/2010 1:11 PM >>> Hi Sandra, Attached please find the completed spreadsheet. Answers to questions: II. * Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. NO * Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? YES

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Sandra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know. Too much snow there??? Dayle Olson

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file:////co-adshare/...ndon/Brevard%20Achievement%20Center/Request%20for%20info%20response%20correspondence%2012.29.10.htm[11/08/2011 11:21:02 AM]

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BREVARD:000079

Please let us know if you have any questions, Dayle _______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you. Tere Sulzbach Benefits & Compensation Administrator

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BREVARD:000080

file:////co-adshare/...ndon/Brevard%20Achievement%20Center/Request%20for%20info%20response%20correspondence%2012.29.10.htm[11/08/2011 11:21:02 AM]

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From: Habit, Sandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 2:31 PM To: 'Dayle Olson' Subject: RE: RE: Waiver Application - Brevard Achievement Center
Dayle, One last question, what is the renewal effective date? Thanks, Sandy From: Dayle Olson [mailto:[email protected]] Sent: Wednesday, December 29, 2010 1:47 PM To: Habit, Sandra (HHS/OCIIO) Cc: Tere Sulzbach Subject: Fwd: RE: Waiver Application - Brevard Achievement Center

Sandra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know. Too much snow there??? Dayle Olson

Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]

Attached please find the completed spreadsheet. Answers to questions: II.

* Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. NO * Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? YES Please let us know if you have any questions, Dayle
BREVARD:000081

file:////co-adshare/...20Team/Brandon/Brevard%20Achievement%20Center/Renewal%20effective%20date%20question%2012.29.10.htm[11/08/2011 11:21:08 AM]

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>>> Tere Sulzbach 12/29/2010 1:11 PM >>> Hi Sandra,

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you. Tere Sulzbach Benefits & Compensation Administrator

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BREVARD:000082

file:////co-adshare/...20Team/Brandon/Brevard%20Achievement%20Center/Renewal%20effective%20date%20question%2012.29.10.htm[11/08/2011 11:21:08 AM]

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From: Tere Sulzbach [[email protected]] Sent: Wednesday, December 29, 2010 2:47 PM To: Habit, Sandra (HHS/OCIIO) Subject: RE: RE: Waiver Application - Brevard Achievement Center Hello Ms. Habit, Yes. We only have two tiers: employee and dependents. Have a great day! tere

Tere Sulzbach Benefits & Compensation Administrator

Sandra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know. Too much snow there??? Dayle Olson [cid:[email protected]] Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]
BREVARD:000083

file:////co-adshare/.../DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Question%20response%2012.29.10.txt[11/08/2011 11:21:14 AM]

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________________________________ From: Dayle Olson [mailto:[email protected]] Sent: Wednesday, December 29, 2010 1:47 PM To: Habit, Sandra (HHS/OCIIO) Cc: Tere Sulzbach Subject: Fwd: RE: Waiver Application - Brevard Achievement Center

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>>> "Habit, Sandra (HHS/OCIIO)" <[email protected]> 12/29/2010 2:27 PM >>> Dayle, Thank you so much for your response. I have one question for you, is the information only to be broken down into employee + family? There are no other tiers available, i.e. employee only, employee + spouse, etc? We were lucky this time around, the snow hit further east! Sandy

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

>>> Tere Sulzbach 12/29/2010 1:11 PM >>> Hi Sandra, Attached please find the completed spreadsheet. Answers to questions: II. * Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. NO

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Tere Sulzbach Benefits & Compensation Administrator

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

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Please let us know if you have any questions, Dayle

file:////co-adshare/.../DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Question%20response%2012.29.10.txt[11/08/2011 11:21:14 AM]

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BREVARD:000084

* Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? YES

From: Habit, Sandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 3:18 PM To: 'Tere Sulzbach' Subject: RE: RE: Waiver Application - Brevard Achievement Center Tere, Would it be possible for you to contact me at 301-492-4175? Thanks, Sandy -----Original Message----From: Tere Sulzbach [mailto:[email protected]] Sent: Wednesday, December 29, 2010 2:47 PM To: Habit, Sandra (HHS/OCIIO) Subject: RE: RE: Waiver Application - Brevard Achievement Center Hello Ms. Habit, Yes. We only have two tiers: employee and dependents. Have a great day! tere

Tere Sulzbach Benefits & Compensation Administrator

________________________________ From: Dayle Olson [mailto:[email protected]] Sent: Wednesday, December 29, 2010 1:47 PM To: Habit, Sandra (HHS/OCIIO) Cc: Tere Sulzbach Subject: Fwd: RE: Waiver Application - Brevard Achievement Center Sandra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know. Too much snow there???
BREVARD:000085

file:////co-adshare/...es/DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Contact%20question%2012.29.10.txt[11/08/2011 11:21:20 AM]

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>>> "Habit, Sandra (HHS/OCIIO)" <[email protected]> 12/29/2010 2:27 PM >>> Dayle, Thank you so much for your response. I have one question for you, is the information only to be broken down into employee + family? There are no other tiers available, i.e. employee only, employee + spouse, etc? We were lucky this time around, the snow hit further east! Sandy

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

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Dayle Olson [cid:[email protected]] Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected] >>> Tere Sulzbach 12/29/2010 1:11 PM >>> Hi Sandra, Attached please find the completed spreadsheet. Answers to questions: II.

* Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. NO

Tere Sulzbach Benefits & Compensation Administrator

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

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Please let us know if you have any questions, Dayle

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* Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? YES

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BREVARD:000086

file:////co-adshare/...es/DFOI%20Processing%20Team/Brandon/Brevard%20Achievement%20Center/Contact%20question%2012.29.10.txt[11/08/2011 11:21:20 AM]

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From: Habit, Sandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 3:37 PM To: 'Tere Sulzbach' Subject: FW: RE: Waiver Application - Brevard Achievement Center Attachments: BAC Waiver Application Form.xls
Tere, As discussed, please fill out the data for the dependents. Thank you,

From: Dayle Olson [mailto:[email protected]] Sent: Wednesday, December 29, 2010 1:47 PM To: Habit, Sandra (HHS/OCIIO) Cc: Tere Sulzbach Subject: Fwd: RE: Waiver Application - Brevard Achievement Center

Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]

>>> Tere Sulzbach 12/29/2010 1:11 PM >>> Hi Sandra, Attached please find the completed spreadsheet. Answers to questions: II. * Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please state the expiration of the last collective bargaining agreement. NO * Please confirm that your plan was in existence before March 23, 2010, and if so, whether it will be complying with the requirements of the Grandfathering Regulation, 45 CFR 147.140? YES
BREVARD:000087

file:////co-adshare/...sing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20additional%20info%2012.29.10.htm[11/08/2011 11:21:25 AM]

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Sandra - -attached is the file (and a brief note) that staff has just completed. If you have any quesitions - please let me know. Too much snow there??? Dayle Olson

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Sandy

Please let us know if you have any questions, Dayle _______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you. Tere Sulzbach Benefits & Compensation Administrator

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BREVARD:000088

file:////co-adshare/...sing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20additional%20info%2012.29.10.htm[11/08/2011 11:21:25 AM]

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ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name

Brevard Achievement Center, Inc. Brevard Achievement Center, Inc.

FL

06/01/2000

Teresa Sulzbach

1845 Cogswell Street

Rockledge

FL

32955

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Policy Name (use a new row for each Applicant policy (Plan/ Policy application) Situs) City Brevard Achievement Center, Inc. Health & Welfare Plan Rockledge Brevard Achievement Center, Inc. Health & Welfare Plan Rockledge

Applicant (Plan/ Policy Plan/ Policy Situs) Effective Date Contact State (mm/dd/yyyy) Name

Street Address

City

State

Phone Number (including Zip Code area code)

FL

06/01/2000

Teresa Sulzbach

1845 Cogswell Street

Rockledge

FL

32955

321-6328610

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Email Address tsulzbach@ba Limited Benefit Yes tsulzbach@ba Limited Benefit Yes

Total Number of Individuals Covered by Type of Current Policy Coverage Plan Overall (include all (e.g., Limited SelfAnnual Benefit, HRA, Insured Individual or dependents Limit (in Rx only, Other) (Yes/No) Group Policy covered) dollars)

Group

(b)(4)

321-6328610

Group

PRA Disclosure Statement

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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 valid OMB control number for this information 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, 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) or suggestions for improving 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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BREVARD:000089

ANNUAL LIMIT WAIVER APPLICATION 2010

Maternity/

Mental Health/ Substance

Rehabilitative/

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(b)(4)

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Preventive/ Plan

Current Essential Benefits Annual Limits (Annual Limit for Each Essential Benefit)

Office Visit Hospital Inpatient Emergency Room R Copays/Coinsurance Copay/Coinsurance Copay/Coinsurance Copay/Co

Coinsura Coinsura nce (if Copay (if nce (if Copay (if Copay (if Coinsuranc Copay (if applicabl e (if applicabl applicabl applicabl applicabl applicabl

BREVARD:000090

ANNUAL LIMIT WAIVER APPLICATION 2010

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Rx ninsurance

Current Monthly Premium Rates or Premium Equivalent Rates (in dollars)*:

Projected Rate Increase that would result from compliance with $750,000 Annual Limit Renewal Monthly Premium Rates or Premium Equivalent Rates if Waiver Granted Restriction (in dollars) (Average Premium by Individual)* (in dollars)*

Coinsuran Employee Employer ce (if Individual/ Employee contribution contribution applicable) Tier* (if applicable) (if applicable)

Total

Employee Employer contribution contribution (if applicable) (if applicable)

Total

Employee Employer contribution contribution (if applicable) (if applicable)

Total

Decrease in Access to Benefits that Projected Rate Increase would result that would result from from compliance with $750,000 compliance Annual Limit Restriction with $750,000 (in dollars)(Average Annual Limit Premium by Individual) Restriction (Difference of Column AT (describe and AQ divided by briefly in cell Column AQ) or in a

Plan Administr ator/ CEO of Health Insuranc e Issuer Name

Title of Individual Providing Attestation

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(b)(4)

Policy Terminated

Teresa Chris Caveness/TPA Sulzbach Plan Coordinator

Policy Terminated

Teresa Chris Caveness/TPA Sulzbach Plan Coordinator

* When completing the columns requesting premium rate information, please express the premium rates as a composite rate (if premiums 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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BREVARD:000091

From: Tere Sulzbach [[email protected]] Sent: Thursday, December 30, 2010 11:06 AM To: Habit, Sandra (HHS/OCIIO) Cc: Dayle Olson Subject: Waiver Application - Brevard Achievement Center Attachments: BAC Waiver Application Form.xls Hello Ms. Habit Here is the worksheet with a second row added containing the maximum allowed for dependents.

Please let us know if you need anything further. Regards, Tere

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Tere Sulzbach Benefits & Compensation Administrator

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

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file:////co-adshare/...cessing%20Team/Brandon/Brevard%20Achievement%20Center/Request%20for%20info%20response%2012.30.10.txt[11/08/2011 11:22:02 AM]

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BREVARD:000092

We have

(b)(4)

employees who have dependent coverage and a total of

(b)(4)

dependents.

From: Botwinick, Alexandra (HHS/OCIIO) Sent: Wednesday, January 12, 2011 11:20 AM To: '[email protected]' Cc: Habit, Sandra (HHS/OCIIO) Subject: Brevard Achievement Center, Inc. Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High Attachments: June 1 .pdf Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Brevard Achievement Center, Inc. . HHS has reviewed your application and made 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,

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Alexandra Botwinick Office of Oversight HHS/OCIIO

[email protected]

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BREVARD:000093

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BREVARD:000094

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BREVARD:000095

From: Botwinick, Alexandra (HHS/OCIIO) Sent: Thursday, January 13, 2011 9:01 AM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Brevard Achievement Center, Inc. Waiver of the Annual Limits Requirements of PHS Act Section 2711

Alexandra Botwinick Office of Oversight HHS/OCIIO (301) 492-4177 [email protected]

This is to confirm your e-mail. Thank you very much. Tere

Tere Sulzbach Benefits & Compensation Administrator

>>> "Botwinick, Alexandra (HHS/OCIIO)" <[email protected]> 1/12/2011 11:19 AM >>> Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Brevard Achievement Center, Inc.. HHS has reviewed your application and made its determination. Please see the attached letter. Please confirm receipt of this letter by replying to this e-mail.
BREVARD:000096

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_______________ Confidentiality Notice: This communication, along with any attachments or documents, may contain information that is confidential, privileged or otherwise exempt from disclosure under Federal Privacy Rules. Under these Rules, you are prohibited from using, retaining or disclosing this material in any manner unless you are the intended recipient. If you are not the intended recipient, please notify the sender immediately by reply e-mail and delete all components of this communication. Thank you.

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Good Morning Ms. Botwinick,

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-----Original Message----From: Tere Sulzbach [mailto:[email protected]] Sent: Thursday, January 13, 2011 8:57 AM To: Botwinick, Alexandra (HHS/OCIIO) Subject: Re: Brevard Achievement Center, Inc. Waiver of the Annual Limits Requirements of PHS Act Section 2711

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Please let me know if I can be of further assistance. Sincerely,

Alexandra Botwinick Office of Oversight HHS/OCIIO [email protected]<mailto:[email protected]>

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BREVARD:000097

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