From: Timothy Klimpl [t.klimpl@hohlaw.

com] Sent: Wednesday, December 01, 2010 11:14 AM To: HHS HealthInsurance (HHS) Cc: v.ohara@hohlaw.com; nycedwf@aol.com Subject: waiver Attachments: Cover Letter for Waiver Application- I.B.E.W. Local 3 Health & Welfare Fund.pdf; Application for Waiver- I.B.E.W Local 3 Health & Welfare Fund.pdf; I.B.E.W. Local 3 HW Fund Plan Booklet_Active.pdf
Dear HHS: Enclosed please find a letter dated December 1, 2010 and application for Waiver from the I.B.E.W. Local 3 Health & Welfare Fund. A Plan Booklet is also attached as part of the application. Very truly yours,

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Timothy S. Klimpl Holm & O'Hara LLP 3 West 35th Street- 9th Floor New York, New York 10001 Tel (212)682-2280, Fax (212)682-2153 t.klimpl@hohlaw.com www.hohlaw.com -----------------------------------------------------------------------------------CONFIDENTIALITY: The information contained in this email is privileged and confidential and is intended exclusively for the addressee. If you have received it in error, please notify the sender by return email and delete it from your system. You should not reproduce, distribute, store, retransmit, use or disclose its contents to anyone. IRS CIRCULAR 230 DISCLOSURE: Toensure compliance with requirements imposed by the IRS, we inform you that any U.S. federal tax advice contained in this communication (including any attachments) is not intended or written to be used, and cannot be used, for the purpose of (i) avoiding penalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein. Thank you for your attention to this matter. -----------------------------------------------------------------------------------

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file:////co-adshare/...Local%203%20New%20York%20City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/waiver.htm[10/27/2011 4:50:40 PM]

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Pages 5 through 38 redacted for the following reasons: ---------------------------Exemption 4

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From: Kottenmeier, Erika (HHS/OCIIO) Sent: Monday, December 13, 2010 2:55 PM To: 't.klimpl@hohlaw.com' Cc: Habit, Sandra (HHS/OCIIO) Subject: Annual Limits Waiver Application

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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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

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Kind Regards, Erika M. Kottenmeier Division of Enforcement Office of Oversight HHS/OCIIO erika.kottenmeier@hhs.gov

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Dear Mr. Klimpl, Thank you for your application on behalf of the IBEW Local 3 NYC Electrical Division Health & Welfare Fund. In order to expedite your application, please provide the following information: I. Please complete the entire annual limits spreadsheet attached to this email. 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. II. In addition, please provide the following information: Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with grandfathering provisions, pursuant to 45 CFR 147.140? Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please provide the date on which the last collective bargaining agreement pursuant to which this plan was negotiated will expire. We realize some of the information we request in the spreadsheet overlaps with information you provided in your application forms, but we request that you provide it in the spreadsheet again in order to standardize the data-collection and formatting process and to ensure the accuracy of the information we request. We assure you that the documents you originally supplied are also being evaluated. In order to complete your application, please provide this information by 5:00 pm, December 15, 2010. 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 for your assistance.

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file:////co-adshare/...%20City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/Request%20for%20info%2012.13.10.htm[10/27/2011 4:51:01 PM]

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From: Kottenmeier, Erika (HHS/OCIIO) Sent: Monday, December 13, 2010 3:30 PM To: 'Timothy Klimpl' Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Annual Limits Waiver Application- no attachment Attachments: Copy of Waiver Application Form.xls
Dear Mr. Klimpl, My apologies for the oversight. Thank you for getting back to me so quickly. The spreadsheet is attached. Please also note that the two first rows are there for examples only and you may choose to overwrite them if you like. Best, Erika Kottenmeier From: Timothy Klimpl [mailto:t.klimpl@hohlaw.com] Sent: Monday, December 13, 2010 3:24 PM To: Kottenmeier, Erika (HHS/OCIIO) Cc: v.ohara@hohlaw.com Subject: RE: Annual Limits Waiver Application- no attachment

Timothy S. Klimpl Holm & O'Hara LLP 3 West 35th Street- 9th Floor New York, New York 10001 Tel (212)682-2280, Fax (212)682-2153 t.klimpl@hohlaw.com www.hohlaw.com -----------------------------------------------------------------------------------CONFIDENTIALITY: The information contained in this email is privileged and confidential and is intended exclusively for the addressee. If you have received it in error, please notify the sender by return email and delete it from your system. You should not reproduce, distribute, store, retransmit, use or disclose its contents to anyone. IRS CIRCULAR 230 DISCLOSURE: Toensure compliance with requirements imposed by the IRS, we inform you that any U.S. federal tax advice contained in this communication (including any attachments) is not intended or written to be used, and cannot be used, for the purpose of (i) avoiding penalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein. Thank you for your attention to this matter. ----------------------------------------------------------------------------------- From: Kottenmeier, Erika (HHS/OCIIO) [mailto:Erika.Kottenmeier@hhs.gov] Sent: Monday, December 13, 2010 2:55 PM To: 't.klimpl@hohlaw.com' Cc: Habit, Sandra (HHS/OCIIO)
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file:////co-adshare/...20and%20Welfare%20Fund/RE%20Annual%20Limits%20Waiver%20Application-%20no%20attachment12.13.10.htm[10/27/2011 4:51:06 PM]

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Dear Ms. Kottenmeier: Thank you for providing the IBEW Local 3 Health & Welfare Fund the opportunity to furnish additional information in support of its application for waiver from the PHS Act 2711 annual limits requirement. In response to your email below, dated December 13, 2010, please note that I did not receive an attached spreadsheet. Upon receipt of the attachment, I will complete the required spreadsheet and remainder of the application. Very truly yours,

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Subject: Annual Limits Waiver Application

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

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Kind Regards, Erika M. Kottenmeier Division of Enforcement Office of Oversight HHS/OCIIO erika.kottenmeier@hhs.gov

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Dear Mr. Klimpl, Thank you for your application on behalf of the IBEW Local 3 NYC Electrical Division Health & Welfare Fund. In order to expedite your application, please provide the following information: I. Please complete the entire annual limits spreadsheet attached to this email. 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. II. In addition, please provide the following information: Confirm whether the plan was in existence prior to March 23, 2010. If so, is the plan in compliance with grandfathering provisions, pursuant to 45 CFR 147.140? Confirm whether the plan was created pursuant to the Taft-Hartley Act. If so, please provide the date on which the last collective bargaining agreement pursuant to which this plan was negotiated will expire. We realize some of the information we request in the spreadsheet overlaps with information you provided in your application forms, but we request that you provide it in the spreadsheet again in order to standardize the data-collection and formatting process and to ensure the accuracy of the information we request. We assure you that the documents you originally supplied are also being evaluated. In order to complete your application, please provide this information by 5:00 pm, December 15, 2010. 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 for your assistance.

file:////co-adshare/...20and%20Welfare%20Fund/RE%20Annual%20Limits%20Waiver%20Application-%20no%20attachment12.13.10.htm[10/27/2011 4:51:06 PM]

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ANNUAL LIMIT WAIVER APPLICATION 2010

Annual Limit Waiver Request Applicant Name Applicant ABC Applicant ABC

Policy Name (use a new row for each Applicant (Plan/ Policy policy application) Situs) City Plan 1 Plan 1 Washington Washington

Applicant (Plan/ Plan/ Policy Policy Effective Date Contact Situs) (mm/dd/yyyy) Name State DC DC 01/01/2011 01/01/2011 Jane Doe Jane Doe

Street Address 100 ABC Drive 100 ABC Drive

City Washington Washington

State DC DC

Phone Number (including Zip Code area code) 1-800-ABC20201 1234 1-800-ABC20202 1234

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Email Address abc@abchea lthplan.com Limited Benefit abc@abchea lthplan.com Limited Benefit Yes Yes

Total Number of Individuals Current Covered by Type of Plan Overall Policy Coverage Annual (include all Self(e.g., Limited Limit (in Benefit, HRA, Insured Individual or dependents dollars) Rx only, Other) (Yes/No) Group Policy covered) Group Group 4,000 2,500 $100,000 $100,000

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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ANNUAL LIMIT WAIVER APPLICATION 2010

Ambulatory None None

Emergency None None

Hospitalization None None

Laboratory None None

Pediatric None None

Maternity/ Newborn None None

Mental Health/ Substance Abuse None None

Rehabilitative/ Devices None None

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Preventive/ Wellness None None Prescription $3,000.00 $3,000.00 $500.00

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

Office Visit Hospital Inpatient Emergency Room Rx Copays/Coinsurance Copay/Coinsurance Copay/Coinsurance Copay/Coninsurance

Coinsura Coinsura Copay (if Coinsuranc Copay (if nce (if Copay (if nce (if Copay (if Coinsuran ce (if applicabl applicabl applicabl applicabl applicabl e (if applicabl Plan applicable) e) e) e) e) e) applicable) e) Deductible $15.00 50.00% 50.00% $100.00 $100.00 50.00% 50.00% $100.00 $100.00 50.00% 50.00% $10.00 $10.00 None None

$1,000.00

$15.00

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Total $925.00 21.71% $1,550.00 22.53%

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)*

Employer Employee Individual/ Employee contribution contribution (if applicable) (if applicable) Tier* Employee Employee + Family $100.00 $105.00 $600.00 $1,100.00

Total $700.00 $1,205.00

Employer Employee contribution contribution (if applicable) (if applicable) $110.00 $115.00 $650.00 $1,150.00

Total $760.00 $1,265.00

Employer Employee contribution contribution (if applicable) (if applicable) $125.00 $150.00 $800.00

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 None None

Plan Administr ator/ CEO of Health Insuranc e Issuer Name Jane Doe Jane Doe

Title of Individual Providing Attestation Plan Administrator Plan Administrator

$1,400.00

* 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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From: Habit, Sandra (HHS/OCIIO) Sent: Thursday, December 30, 2010 3:55 PM To: 'nycedwf@aol.com' Subject: IBEW Local 3 NYC Electrical Division Health & Welfare Fund Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Afternoon, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for IBEW Local 3 NYC Electrical Division Health & Welfare Fund. 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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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 Sandra.Habit@hhs.gov

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file:////co-adshare/...203%20New%20York%20City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/IBEWLO~1.HTM[10/27/2011 4:51:15 PM]

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From: NYCEDWF@aol.com Sent: Wednesday, January 12, 2011 12:55 PM To: Habit, Sandra (HHS/OCIIO) Subject: Re: IBEW Local 3 NYC Electrical Division Health & Welfare Fund Approval Lette... WE RECIEVED YOUR EMAIL Linda Perrera NYC ELECTRICIAL DIVISION HEALTH & WELFARE FUND PO Box 650479 Fresh Meadows, NY 11365 P: 718-820-1690 F: 718-820-1691 In a message dated 12/30/2010 3:55:28 P.M. Eastern Standard Time, Sandra.Habit@hhs.gov writes:

Please confirm receipt of this letter by replying to this e-mail.

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

Sandy Habit

Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@hhs.gov

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file:////co-adshare/...York%20City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/Approval%20receipt%201.12.11.htm[10/27/2011 4:51:18 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 IBEW Local 3 NYC Electrical Division Health & Welfare Fund. HHS has reviewed your application and made its determination. Please see the attached letter.

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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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file:////co-adshare/...York%20City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/Approval%20receipt%201.12.11.htm[10/27/2011 4:51:18 PM]

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From: Kottenmeier, Erika (HHS/OCIIO) Sent: Wednesday, February 02, 2011 10:33 AM To: 'Timothy Klimpl' Cc: Habit, Sandra (HHS/OCIIO) Subject: Approval letter for IBEW Local 3 Health & Welfare Fund Attachments: Updated Jan 1 Approval Letter .pdf
Dear Mr. Klimpl, Attached is the approval letter the IBEW Local 3 Health & Welfare Fund received in January for their annual limits waiver. The letter is not customized to them specifically. The content of the email they received is as follows:

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

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I hope this resolves any questions you have. If you have any more please do not hesitate to ask me. Best, Erika M. Kottenmeier Division of Enforcement Center for Consumer Information & Insurance Oversight U.S. Department of Health & Human Services (301) 492-4170 erika.kottenmeier@hhs.gov

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extent of the law.

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Good Afternoon, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for IBEW Local 3 NYC Electrical Division Health & Welfare Fund. 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.

file:////co-adshare/...0York%20City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/Approval%20resent%202.2.11.htm[10/27/2011 4:51:19 PM]

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From: Kottenmeier, Erika (HHS/OCIIO) Sent: Wednesday, February 02, 2011 11:08 AM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Approval letter for IBEW Local 3 Health & Welfare Fund

From: Timothy Klimpl [mailto:t.klimpl@hohlaw.com] Sent: Wednesday, February 02, 2011 10:56 AM To: Kottenmeier, Erika (HHS/OCIIO) Subject: RE: Approval letter for IBEW Local 3 Health & Welfare Fund

Dear Mr. Klimpl, Attached is the approval letter the IBEW Local 3 Health & Welfare Fund received in January for their annual limits waiver. The letter is not customized to them specifically. The content of the email they received is as follows:

Good Afternoon, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for IBEW Local 3 NYC Electrical Division Health & Welfare Fund. HHS has reviewed your application and made its determination. Please see the attached letter.
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file:////co-adshare/...City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/Approval%20resent%20receipt%202.2.11.htm[10/27/2011 4:51:20 PM]

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From: Kottenmeier, Erika (HHS/OCIIO) [mailto:Erika.Kottenmeier@hhs.gov] Sent: Wednesday, February 02, 2011 10:33 AM To: 'Timothy Klimpl' Cc: Habit, Sandra (HHS/OCIIO) Subject: Approval letter for IBEW Local 3 Health & Welfare Fund

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Timothy S. Klimpl Holm & O'Hara LLP 3 West 35th Street- 9th Floor New York, New York 10001 Tel (212)682-2280, Fax (212)682-2153 t.klimpl@hohlaw.com www.hohlaw.com -----------------------------------------------------------------------------------CONFIDENTIALITY: The information contained in this email is privileged and confidential and is intended exclusively for the addressee. If you have received it in error, please notify the sender by return email and delete it from your system. You should not reproduce, distribute, store, retransmit, use or disclose its contents to anyone. IRS CIRCULAR 230 DISCLOSURE: Toensure compliance with requirements imposed by the IRS, we inform you that any U.S. federal tax advice contained in this communication (including any attachments) is not intended or written to be used, and cannot be used, for the purpose of (i) avoiding penalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein. Thank you for your attention to this matter. ------------------------------------------------------------------------------------

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Dear Ms. Kottenmeier: Thank you for your assistance. Your email has answered all my questions in this regard. Very truly yours,

Please confirm receipt of this letter by replying to this e-mail. Please let me know if I can be of further assistance.
I hope this resolves any questions you have. If you have any more please do not hesitate to ask me. Best, Erika M. Kottenmeier Division of Enforcement Center for Consumer Information & Insurance Oversight U.S. Department of Health & Human Services (301) 492-4170 erika.kottenmeier@hhs.gov

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

extent of the 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

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disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full

file:////co-adshare/...City%20Electrical%20Division%20Health%20and%20Welfare%20Fund/Approval%20resent%20receipt%202.2.11.htm[10/27/2011 4:51:20 PM]

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