Brevard Achievement Center - Redacted HWM
Brevard Achievement Center - Redacted HWM
Brevard Achievement Center - Redacted HWM
pl
et eC
ol o
ra do .
(b)(4) (b)(4) (b)(4)
co m
BREVARD:000001
Co m pl et eC ol o ra do . co m
BREVARD:000002
Co m
pl
et eC
ol o
ra do .
BREVARD:000003
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000004
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000005
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000006
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000007
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000008
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000009
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000010
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000011
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000012
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000013
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000014
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000015
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000016
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000017
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000018
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000019
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000020
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000021
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000022
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000023
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000024
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000025
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000026
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000027
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000028
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000029
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000030
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000031
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000032
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000033
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000034
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000035
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000036
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000037
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000038
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000039
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000040
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000041
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000042
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000043
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000044
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000045
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000046
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000047
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000048
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000049
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000050
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000051
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000052
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000053
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000054
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000055
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000056
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000057
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000058
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000059
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000060
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000061
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000062
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000063
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000064
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000065
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000066
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000067
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000068
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000069
co m
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.
Co m
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.
pl
et eC
Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 [email protected]
ol o
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
ra do .
co m
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.
Co m
pl
et eC
ol o
ra do .
co m
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.
pl
et eC
ol o
ra do .
co m
Login High (60): Pass Medium (75): Pass Low (90): Pass
From: [email protected]
Co m
Message Score: 1 My Spam Blocking Level: High Block this sender Block hhs.gov
This message was delivered because the content filter score did not exceed your filter level.
BREVARD:000072
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
Co m
pl
et eC
ol o
ra do .
BREVARD:000073
Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]
co m
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]
Co m
pl
et eC
ol o
ra do .
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
co m
BREVARD:000074
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
Co m
pl
et eC
* 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
ol o
ra do .
BREVARD:000075
Dayle Olson President Brevard Achievement Center 1845 Cogswell Street Rockledge, Florida 32955 [email protected]
co m
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
FL
06/01/2000
Teresa Sulzbach
ra do .c om
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
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.
Co m
pl
et eC
ol o
BREVARD:000076
Ambulatory
Emergency
Hospitalization
Laboratory
Pediatric
Maternity/ Newborn
Rehabilitative/ Devices
(b)(4)
Co m
pl
et eC
ol o
ra do .c om
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)
BREVARD:000077
ra do .c om
Rx ninsurance
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
Total
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
(b)(4)
Policy Terminated
* 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).
Co m
pl
et eC
ol o
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
Co m
pl
et eC
ol o
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
ra do .
co m
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
Co m
pl
et eC
ol o
ra do .
BREVARD:000080
co m
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]
* 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
Co m
pl
et eC
ol o
ra do .
co m
_______________ 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
Co m
pl
et eC
ol o
ra do .
BREVARD:000082
co m
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
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
Co m
________________________________ 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
pl
et eC
>>> "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
ol o
ra do .
co m
_______________ 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
Co m
pl
et eC
ol o
_______________ 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.
ra do .
co m
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
________________________________ 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
Co m
>>> "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
pl
et eC
ol o
_______________ 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.
ra do .
co m
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
Co m
_______________ 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.
pl
et eC
ol o
* 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
ra do .
BREVARD:000086
co m
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
Co m
pl
et eC
ol o
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
ra do .
co m
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
Co m
pl
et eC
ol o
ra do .
BREVARD:000088
co m
FL
06/01/2000
Teresa Sulzbach
Rockledge
FL
32955
ol o
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
FL
06/01/2000
Teresa Sulzbach
Rockledge
FL
32955
321-6328610
ra do .c om
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
Co m
pl
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.
et eC
BREVARD:000089
Maternity/
Rehabilitative/
Co m
pl
et eC
ol o
(b)(4)
ra do .c om
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
ra do .c om
Rx ninsurance
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
Total
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
ol o
(b)(4)
Policy Terminated
Policy Terminated
* 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).
Co m
pl
et eC
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.
Co m
pl
et eC
ol o
_______________ 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.
ra do .
co m
BREVARD:000092
We have
(b)(4)
(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,
et eC pl
Co m
ol o
ra do .
co m
BREVARD:000093
Co m pl et eC ol o ra do . co m
BREVARD:000094
Co m pl et eC ol o ra do . co m
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
>>> "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
Co m
_______________ 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.
pl
et eC
ol o
ra do .
-----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
co m
Co m
pl
et eC
ol o
ra do .
BREVARD:000097
co m