Teamsters Local Union No. 72 - Redacted Bates HW

From: Jennifer Goldstein [jgoldstein@local72.
org] Sent: Tuesday, November 09, 2010 1:09 PM To: HHS HealthInsurance (HHS) Cc: kcclor@gmail.com Subject: "WAIVER" Follow Up Flag: Follow up Flag Status: Completed
Document obtained by CompleteColorado.com
Attachments: Waiver from restrictions of annual limits.pdf

Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email: jgoldstein@local72.org
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file:///T|/...20NO%2012600%20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/WAIVER.htm[08/04/2011 12:09:13 PM]
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From: Moultrie, Cam (HHS/OCIIO) Sent: Tuesday, November 16, 2010 1:40 PM To: jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund
EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
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In order to complete your application, please provide this information by 5:00 pm, November 17, 2010. We look forward to receiving your completed application. Thank you. Cam L. Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
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Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied)
file:///T|/...OW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%2011.16.10.htm[08/04/2011 12:09:15 PM]
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From: Moultrie, Cam (HHS/OCIIO) Sent: Wednesday, November 17, 2010 12:53 PM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Waiver Application for Teamsters Local 72 Welfare Fund
Cam Lynne Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
From: Moultrie, Cam (HHS/OCIIO) Sent: Wednesday, November 17, 2010 12:27 PM To: 'jgoldstein@local72.org' Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Tuesday, November 16, 2010 2:25 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Ms. Moultrie, I have attached the additional information you were looking for. Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email: jgoldstein@local72.org
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Tuesday, November 16, 2010 1:40 PM To: jgoldstein@local72.org
Teams L72:000006
file:///T|/...ters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20response%2011.17.10.htm[08/04/2011 12:09:15 PM]
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Thank you for your response. On you application you stated that the The Plan currently has an overall calendar year limit of on medical benefits and the following annual limits on specific medical benefits. What is the Plans overall calendar year limit? Do you have premium rates for employee+ family? Thanks again. Cam Moultrie
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Document obtained by CompleteColorado.com Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund
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EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
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file:///T|/...ters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20response%2011.17.10.htm[08/04/2011 12:09:15 PM]
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From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, November 18, 2010 10:51 AM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Waiver Application for Teamsters Local 72 Welfare Fund
Cam Lynne Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Wednesday, November 17, 2010 3:29 PM To: Moultrie, Cam (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Wednesday, November 17, 2010 12:27 PM To: jgoldstein@local72.org Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Teams L72:000008
file:///T|/...0Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20correspondence%2011.171.0.htm[08/04/2011 12:09:16 PM]
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265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email: jgoldstein@local72.org
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The Plan is a supplemental benefit plan that provides prescription drug and dental benefits to its active participants and their eligible dependents.This supplemental coverageis paid for by a contribution rate agreed upon in collective bargaining between the New York State Thruway Authority and the Union. The New York State Thruway Authorityprovides these same participants withhospital and medical coverage. The Plan has a $Ex. 4 calendar year maximum on its prescription drug benefit, and that is the only essential benefit the Fund sting a waiver for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Tuesday, November 16, 2010 1:40 PM To: jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund
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Ms. Moultrie, I have attached the additional information you were looking for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Document obtained by CompleteColorado.com In order to complete your application, please provide this information by 5:00 pm, November 17, 2010. We look forward to receiving your completed application. Thank you. Cam L. Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, November 18, 2010 11:39 AM To: jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Thank you. Please provide the COBRA equivalency rates. Cam Lynne Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
Thank you for your response. On you application you stated that the The Plan currently has an overall calendar year limit of on medical benefits and the following annual limits on specific medical benefits. What is the Plans overall calendar year limit? Do you have premium rates for employee+ family?
Teams L72:000011
file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20addtional%20info%2011.18.10.htm[08/04/2011 12:09:16 PM]
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The Plan is a supplemental benefit plan that provides prescription drug and dental benefits to its active participants and their eligible dependents.This supplemental coverageis paid for by a contribution rate agreed upon in collective bargaining between the New York State Thruway Authority and the Union. The New York State Thruway Authorityprovides these same participants withhospital and medical coverage. The Plan has a $ Ex. 4 calendar year maximum on its prescription drug benefit, and that is the only essential benefit the Fund is requesting a waiver for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Thanks again. Cam Moultrie
Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier)
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Family (if applicable or other appropriate tier)
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From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, November 18, 2010 4:21 PM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Waiver Application for Teamsters Local 72 Welfare Fund
Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Thursday, November 18, 2010 12:02 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Teams L72:000014
file:///T|/...Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20additional%20info%20response%2011.18.10.htm[08/04/2011 12:09:17 PM]
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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, November 18, 2010 11:39 AM To: jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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Prescription COBRA for an individual is $Ex. 4 and for a family it is $Ex. 4 Please forward any future questions to the Funds Council, Kevin C. Clor Esq. at kcclor@gmail.com Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Ms. Moultrie, I have attached the additional information you were looking for. Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228
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Document obtained by CompleteColorado.com The Plan is a supplemental benefit plan that provides prescription drug and dental benefits to its active participants and their eligible dependents.This supplemental coverageis paid for by a contribution rate agreed upon in collective bargaining between the New York State Thruway Authority and the Union. The New York State Thruway Authorityprovides these same participants withhospital and medical coverage. Ex. 4 The Plan has a $ calendar year maximum on its prescription drug benefit, and that is the only essential benefit the Fund esting a waiver for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
Fax: 212-645-5026 Email: jgoldstein@local72.org
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From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, November 18, 2010 4:33 PM To: Kevin Clor Cc: jgoldstein@local72.org; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Prescription COBRA for an individual is $Ex. 4 and for a family it is $Ex. 4 Please forward any future questions to the Funds Council, Kevin C. Clor Esq. at kcclor@gmail.com Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email: jgoldstein@local72.org
Teams L72:000017
file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/3rd%20Request%20for%20additional%20info%2011.18.10.htm[08/04/2011 12:09:17 PM]
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Thank you. Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
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Mr. Clor, I am interested in COBRA equivalencies for 2010, 2011 (if waiver is approved) and 2011 (if the waiver is not approved). I have provided a sample chart below for your convenience: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied)
Document obtained by CompleteColorado.com From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, November 18, 2010 11:39 AM To: jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Thank you for your response. On you application you stated that the The Plan currently has an overall calendar year limit of on medical benefits and the following annual limits on specific medical benefits. What is the Plans overall calendar year limit? Do you have premium rates for employee+ family?
Teams L72:000018
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The Plan is a supplemental benefit plan that provides prescription drug and dental benefits to its active participants and their eligible dependents.This supplemental coverageis paid for by a contribution rate agreed upon in collective bargaining between the New York State Thruway Authority and the Union. The New York State Thruway Authorityprovides these same participants withhospital and medical coverage. The Plan has a $Ex. 4 calendar year maximum on its prescription drug benefit, and that is the only essential benefit the Fund sting a waiver for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Thanks again. Cam Moultrie
Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier)
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Family (if applicable or other appropriate tier)
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From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, December 02, 2010 7:31 PM To: Kevin Clor Cc: jgoldstein@local72.org; Pavesi, Matthew C.; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Mr. Clor, Per my voicemail, please call me to discuss your response. Thank you, Cam Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
***** Confidentiality Statement****** The information contained in this transmission may contain privileged and confidential information. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
Kevin C. Clor, Esq. 38 Thomas Jefferson Lane

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file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]
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Ms. Moultrie: The COBRA equivalency for 20 1 with the $Ex. 4 max and w/o the $ Ex. 4 max are based onthe rates we have already included in the application plus 4 % which is wed under thelaw. ope this answers your question. Please advise if you need any additional infor ation. Thank you. KCC
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From: Kevin Clor [mailto:kcclor@gmail.com] Sent: Thursday, December 02, 2010 7:27 PM To: Moultrie, Cam (HHS/OCIIO) Cc: jgoldstein@local72.org; Pavesi, Matthew C.; Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund
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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 disclosure may result in prosecution to the full extent of the law.
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Snyder, New York 14226 Office (716) 839-0418 Fax (716) 839-1834 Email:kcclor@gmail.com

On Dec 2, 2010, at 7:19 PM, Moultrie, Cam (HHS/OCIIO) wrote:

No, I did not receive a response to my last email regarding the COBRA equivalencies for 2010 and 2011. Please note that we cannot process your application until we have received all of the necessary information. You will receive a decision within 30 days of when we receive all of the requested information. We look forward to receiving your completed application. Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
Good Morning, I am just checking in to make sure you received all the information that you needed for our waiver application. Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228
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From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Thursday, December 02, 2010 10:15 AM To:Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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Fax: 212-645-5026 Email:jgoldstein@local72.org
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, November 18, 2010 4:33 PM To:Kevin Clor Cc: jgoldstein@local72.org; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Thursday, November 18, 2010 12:02 PM To:Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Prescription COBRA for an individual is $Ex. 4 and for a family it is $Ex. 4 Please forward any future questions to the Funds Council, Kevin C. Clor Esq. atkcclor@gmail.com Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228
Teams L72:000023
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Fax: 212-645-5026 Email:jgoldstein@local72.org
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, November 18, 2010 11:39 AM To:jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Wednesday, November 17, 2010 3:29 PM To:Moultrie, Cam (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email:jgoldstein@local72.org
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Wednesday, November 17, 2010 12:27 PM To:jgoldstein@local72.org Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Thank you for your response. On you application you stated that the The Plan currently has an overall calendar year limit of on medical benefits and the following annual limits on specific medical benefits. What is the Plans overall calendar year limit?
Teams L72:000024
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The Plan is a supplemental benefit plan that provides prescription drug and dental benefits to its active participants and their eligible dependents.This supplemental coverageis paid for by a contribution rate agreed upon in collective bargaining between the New York State Thruway Authority and the Union. The New York State Thruway Authorityprovides these same participants withhospital and medical coverage. Ex. 4 The Plan has a $ calendar year maximum on its prescription drug benefit, and that is the only essential benefit the Fund sting a waiver for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Document obtained by CompleteColorado.com Do you have premium rates for employee+ family? Thanks again. Cam Moultrie
From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Tuesday, November 16, 2010 2:25 PM To:Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE EE + Child (if applicable or other appropriate tier)
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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Tuesday, November 16, 2010 1:40 PM To:jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund
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EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
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From: Moultrie, Cam (HHS/OCIIO) Sent: Thursday, December 02, 2010 7:20 PM To: jgoldstein@local72.org Cc: Kevin Clor; Pavesi, Matthew C.; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, November 18, 2010 4:33 PM To: Kevin Clor Cc: jgoldstein@local72.org; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Teams L72:000027
file:///T|/...onse%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%2012.2.10.htm[08/04/2011 12:09:19 PM]
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Good Morning, I am just checking in to make sure you received all the information that you needed for our waiver application. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Thursday, December 02, 2010 10:15 AM To: Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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Document obtained by CompleteColorado.com Mr. Clor, I am interested in COBRA equivalencies for 2010, 2011 (if waiver is approved) and 2011 (if the waiver is not approved). I have provided a sample chart below for your convenience: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied)
From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, November 18, 2010 11:39 AM To: jgoldstein@local72.org Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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Ex. 4 Prescription COBRA for an individual is $ and for a family it is $Ex. 4 Please forward any future questions to the Funds Council, Kevin C. Clor Esq. at kcclor@gmail.com Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Document obtained by CompleteColorado.com Thank you. Please provide the COBRA equivalency rates. Cam Lynne Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
From: Jennifer Goldstein [mailto:jgoldstein@local72.org]
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The Plan is a supplemental benefit plan that provides prescription drug and dental benefits to its active participants and their eligible dependents.This supplemental coverageis paid for by a contribution rate agreed upon in collective bargaining between the New York State Thruway Authority and the Union. The New York State Thruway Authorityprovides these same participants withhospital and medical coverage. Ex. 4 The Plan has a $ calendar year maximum on its prescription drug benefit, and that is the only essential benefit the Fund is requesting a waiver for. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Sent: Tuesday, November 16, 2010 2:25 PM Document obtained by CompleteColorado.com To: Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Ms. Moultrie, I have attached the additional information you were looking for. Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email: jgoldstein@local72.org
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Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
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In order to complete your application, please provide this information by 5:00 pm, November 17, 2010. We look
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Document obtained by CompleteColorado.com forward to receiving your completed application. Thank you. Cam L. Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
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From: Kevin Clor [kcclor@gmail.com] Sent: Thursday, December 02, 2010 7:27 PM To: Moultrie, Cam (HHS/OCIIO) Cc: jgoldstein@local72.org; Pavesi, Matthew C.; Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund Ms. Moultrie: The COBRA equivalency for 2011 with the $ Ex. 4 max and w/o the $ Ex. 4 max are based onthe rates we have already included in the application plus Ex. wed under thelaw. ope this answers your question. Please advise 4 % which is a if you need any additional infor ation. Thank you. KCC
From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Thursday, December 02, 2010 10:15 AM To:Moultrie, Cam (HHS/OCIIO)
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file:///T|/...LLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%20response%2012.2.10.htm[08/04/2011 12:09:19 PM]
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Kevin C. Clor, Esq. 38 Thomas Jefferson Lane Snyder, New York 14226 Office (716) 839-0418 Fax (716) 839-1834 Email:kcclor@gmail.com
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Document obtained by CompleteColorado.com Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
Good Morning, I am just checking in to make sure you received all the information that you needed for our waiver application. Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email:jgoldstein@local72.org
Prescription COBRA for an individual is $Ex. 4 and for a family it is $Ex. 4 Please forward any future questions to the Funds Council, Kevin C. Clor Esq. atkcclor@gmail.com Thanks and regards, Jennifer S. Goldstein Titan Administrator 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026
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Mr. Clor, I am interested in COBRA equivalencies for 2010, 2011 (if waiver is approved) and 2011 (if the waiver is not approved). I have provided a sample chart below for your convenience: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier) Thank you. Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
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Email:jgoldstein@local72.org
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Document obtained by CompleteColorado.com 265 West 14 th Street, Suite 704, New York, NY 10011 Phone: 212-691-4228 Fax: 212-645-5026 Email:jgoldstein@local72.org
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Dear Ms. Goldstein: Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information: Please state your plans overall annual limit. Please provide the current monthly premium rates and the projected monthly premium rates applicable to the plan or policy forms if the plan were to comply with the restricted annual benefits. In other words, we would like a chart that reflects the following information: 2010 January Premium 2011 January Premium 2011 January Premium (current level) (renewal) (if $750,000 annual limit was applied) EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier) In order to complete your application, please provide this information by 5:00 pm, November 17, 2010. We look forward to receiving your completed application. Thank you. Cam L. Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
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Mr. Clor, Per my voicemail, please call me to discuss your response. Thank you, Cam Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services
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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Thursday, December 02, 2010 7:31 PM To: Kevin Clor Cc: jgoldstein@local72.org; Pavesi, Matthew C.; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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From: Pavesi, Matthew C. [MPavesi@segalco.com] Sent: Friday, December 03, 2010 5:05 PM To: Moultrie, Cam (HHS/OCIIO); Kevin Clor Cc: jgoldstein@local72.org; Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund Cam, As a follow-up to our telephone conversation from today, here is the information you requested: Ex. 4 Aggregate employer contributions for 2010: $ Average monthly employer contributions for 2010: $Ex. 4 The plan provides dental benefits, life insurance and a disability benefit as well that is paid for with these employer contributions along with reasonable administrative expenses. The 2010 per member per month expense for the Plans current $ Ex. 4 annual dollar maximum for Ex. 4 prescription drugs is $ Applying trend, the 2011 projected mber per month expense for the Plans current $Ex. 4 annual Ex. 4 maximum for prescription drugs is $ Applying trend, the 2011 projected per member per month expense increasing the annual maximum to $750,000 is $Ex. 4 Please let me know if there is any further information you need to consider the Funds application. Best regards, Matt Matthew Pavesi Benefits Consultant The Segal Company 333 West 34th Street, New York, New York 10001-2402 ( Tel 212.251.5339 | Fax 212.251.5490 . mpavesi@segalco.com
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(301) 492-4174 cam.moultrie@hhs.gov
From: Kevin Clor [mailto:kcclor@gmail.com] Sent: Thursday, December 02, 2010 7:27 PM To: Moultrie, Cam (HHS/OCIIO) Cc: jgoldstein@local72.org; Pavesi, Matthew C.; Habit, Sandra (HHS/OCIIO) Subject: Waiver Application for Teamsters Local 72 Welfare Fund
Kevin C. Clor, Esq. 38 Thomas Jefferson Lane Snyder, New York 14226 Office (716) 839-0418 Fax (716) 839-1834 Email:kcclor@gmail.com


No, I did not receive a response to my last email regarding the COBRA equivalencies for 2010 and 2011. Please note that we cannot process your application until we have received all of the necessary information. You will receive
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Ms. Moultrie: Ex. 4 The COBRA equivalency for 2 1 with the $ max and w/o the $ Ex. 4 max are based onthe rates we have already included in the application plus Ex. wed under thelaw. ope this answers your question. Please advise 4 % which is if you need any additional infor ation. Thank you. KCC
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From: Jennifer Goldstein [mailto:jgoldstein@local72.org] Sent: Thursday, December 02, 2010 10:15 AM To:Moultrie, Cam (HHS/OCIIO) Cc: Kevin Clor; Pavesi, Matthew C. Subject: RE: Waiver Application for Teamsters Local 72 Welfare Fund
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Good Morning, I am just checking in to make sure you received all the information that you needed for our waiver application. Thanks and regards, Jennifer S. Goldstein Titan Administrator
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obtained by CompleteColorado.com a decision within 30 days of when we receiveDocument all of the requested information. We look forward to receiving your completed application. Cam Lynne Moultrie Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services (301) 492-4174 cam.moultrie@hhs.gov
Thank you. Please provide the COBRA equivalency rates. Cam Lynne Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services
Teams L72:000039
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Ex. 4 Prescription COBRA for an individual is $ and for a family it is $Ex. 4 Please forward any future questions to the Funds Council, Kevin C. Clor Esq. atkcclor@gmail.com Thanks and regards, Jennifer S. Goldstein Titan Administrator
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Ms. Moultrie, I have attached the additional information you were looking for.
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Thanks and regards, Jennifer S. Goldstein Titan Administrator
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In order to complete your application, please provide this information by 5:00 pm, November 17, 2010. We look forward to receiving your completed application. Thank you. Cam L. Moultrie Program Analyst Office of Consumer Information and Insurance Oversight U.S. Department of Health and Human Services
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THISMESSAGEISINTENDEDONLYFORTHEUSEOFTHE ADDRESSEE.ITMAYCONTAINPRIVILEGEDORCONFIDENTIAL INFORMATIONTHATISEXEMPTFROMDISCLOSURE.Dissemination, distributionorcopyingofthismessagebyanyoneotherthantheaddresseeis strictlyprohibited.Ifyoureceivedthismessageinerror,pleasenotifyus immediatelybyreplying:"Receivedinerror"anddeletethemessage. Thankyou.
From: Botwinick, Alexandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 1:45 PM To: jgoldstein@local72.org Subject: Teamsters Local Union No. 72 Waiver of the Annual Limits Requirements 12-29-2010 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Afternoon,
Please confirm receipt of this letter by replying to this e-mail.
Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov
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Please let me know if I can be of further assistance.
Sincerely,
file:///T|/...600%20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Approval%2012.29.10.htm[08/04/2011 12:09:21 PM]
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Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Teamsters Local Union No. 72. HHS has reviewed your application and made its determination. Please see the attached letter.
From: Botwinick, Alexandra (HHS/OCIIO) Sent: Wednesday, December 29, 2010 1:45 PM To: jgoldstein@local72.org Subject: Teamsters Local Union No. 72 Waiver of the Annual Limits Requirements 12-29-2010 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Afternoon,
Please confirm receipt of this letter by replying to this e-mail.
Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov
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Teams L72:000044
Please let me know if I can be of further assistance.
Sincerely,
file:///T|/...sters%20Local%20Union%20No.%2072%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-29-2010.htm[08/04/2011 12:09:21 PM]
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Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Teamsters Local Union No. 72. HHS has reviewed your application and made its determination. Please see the attached letter.
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Teamsters Local Union No. 72 - Redacted Bates HW

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Teamsters Local Union No. 72 - Redacted Bates HW

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From: Jennifer Goldstein [jgoldstein@local72.

Document obtained by CompleteColorado.com

Attachments: Waiver from restrictions of annual limits.pdf

file:///T|/...20NO%2012600%20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/WAIVER.htm[08/04/2011 12:09:13 PM]

Document obtained by CompleteColorado.com

Document obtained by CompleteColorado.com

Document obtained by CompleteColorado.com

Document obtained by CompleteColorado.com

file:///T|/...OW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%2011.16.10.htm[08/04/2011 12:09:15 PM]

Document obtained by CompleteColorado.com

file:///T|/...ters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20response%2011.17.10.htm[08/04/2011 12:09:15 PM]

file:///T|/...ters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20response%2011.17.10.htm[08/04/2011 12:09:15 PM]

Document obtained by CompleteColorado.com

file:///T|/...0Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20correspondence%2011.171.0.htm[08/04/2011 12:09:16 PM]

Document obtained by CompleteColorado.com

file:///T|/...0Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20correspondence%2011.171.0.htm[08/04/2011 12:09:16 PM]

file:///T|/...0Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20additional%20info%20correspondence%2011.171.0.htm[08/04/2011 12:09:16 PM]

Document obtained by CompleteColorado.com

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20addtional%20info%2011.18.10.htm[08/04/2011 12:09:16 PM]

Thanks again. Cam Moultrie

Document obtained by CompleteColorado.com

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20addtional%20info%2011.18.10.htm[08/04/2011 12:09:16 PM]

Family (if applicable or other appropriate tier)

Document obtained by CompleteColorado.com

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20addtional%20info%2011.18.10.htm[08/04/2011 12:09:16 PM]

Document obtained by CompleteColorado.com

file:///T|/...Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20additional%20info%20response%2011.18.10.htm[08/04/2011 12:09:17 PM]

file:///T|/...Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20additional%20info%20response%2011.18.10.htm[08/04/2011 12:09:17 PM]

Fax: 212-645-5026 Email: jgoldstein@local72.org

Document obtained by CompleteColorado.com

file:///T|/...Local%20Union%20%2372%20Welfare%20Fund/2nd%20Request%20for%20additional%20info%20response%2011.18.10.htm[08/04/2011 12:09:17 PM]

Document obtained by CompleteColorado.com

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/3rd%20Request%20for%20additional%20info%2011.18.10.htm[08/04/2011 12:09:17 PM]

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/3rd%20Request%20for%20additional%20info%2011.18.10.htm[08/04/2011 12:09:17 PM]

Thanks again. Cam Moultrie

Document obtained by CompleteColorado.com

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/3rd%20Request%20for%20additional%20info%2011.18.10.htm[08/04/2011 12:09:17 PM]

Family (if applicable or other appropriate tier)

Document obtained by CompleteColorado.com

file:///T|/...eamsters%20Local%20Union%20%2372%20Welfare%20Fund/3rd%20Request%20for%20additional%20info%2011.18.10.htm[08/04/2011 12:09:17 PM]

Document obtained by CompleteColorado.com

Kevin C. Clor, Esq. 38 Thomas Jefferson Lane

file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]

Document obtained by CompleteColorado.com

On Dec 2, 2010, at 7:19 PM, Moultrie, Cam (HHS/OCIIO) wrote:

file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]

Fax: 212-645-5026 Email:jgoldstein@local72.org

Document obtained by CompleteColorado.com

file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]

Fax: 212-645-5026 Email:jgoldstein@local72.org

Document obtained by CompleteColorado.com

file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]

file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]

Document obtained by CompleteColorado.com

file:///T|/...20Response%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Correspondence%2012.2.10.htm[08/04/2011 12:09:18 PM]

Document obtained by CompleteColorado.com

file:///T|/...onse%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%2012.2.10.htm[08/04/2011 12:09:19 PM]

file:///T|/...onse%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%2012.2.10.htm[08/04/2011 12:09:19 PM]

file:///T|/...onse%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%2012.2.10.htm[08/04/2011 12:09:19 PM]

file:///T|/...onse%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%2012.2.10.htm[08/04/2011 12:09:19 PM]

file:///T|/...onse%20[YELLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%2012.2.10.htm[08/04/2011 12:09:19 PM]

Document obtained by CompleteColorado.com

file:///T|/...LLOW]/Teamsters%20Local%20Union%20%2372%20Welfare%20Fund/Request%20for%20info%20response%2012.2.10.htm[08/04/2011 12:09:19 PM]