From: Donna VanAllan [dvanallan@sencayarc.

org] Sent: Wednesday, November 24, 2010 1:18 PM To: HHS HealthInsurance (HHS) Cc: bkaminski@sencayarc.org Subject: Waiver Attachments: waiver app.pdf

Document obtained by CompleteColorado.com

See attached Waiver Application and required documents (within one attachment). Please contact Bill Kaminski, Director of Human Resources, at 315-539-5067 if you have any questions, or require additional information. Donna VanAllan ------Donna VanAllan Executive Assistant Seneca Cayuga ARC 315-539-5067, ext. 117

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Seneca ARC:000001

file:///T|/...0-%20YELLOW/Applications%20with%20NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Waiver.txt[08/12/2011 3:51:05 PM]

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Document obtained by CompleteColorado.com

Ex. 4 Ex. 4

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Ex. 4

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Seneca ARC:000002

Document obtained by CompleteColorado.com

Pages 3 through 17 redacted for the following reasons: ---------------------------Exemption 4

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Seneca ARC:000003

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From: Kottenmeier, Erika (HHS/OCIIO) Sent: Thursday, December 09, 2010 12:25 PM To: 'bkaminski@sencayarc.org' Cc: Habit, Sandra (HHS/OCIIO) Subject: Annual Limits Waiver Application

Document obtained by CompleteColorado.com

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

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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 extent of the law.

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Dear Mr. Kaminski, Thank you for your application on behalf of Seneca Cayuga ARCs Standalone HRA. Before we can complete processing your application, we need several items of information from you. Specifically, please provide the following: The number of enrollees in the plan (including dependents) The amount the employer contributes to each employee A signed attestation as it is stated in the September 3, 2010 OCIIO Sub-Regulatory guidance. The attestation must include a statement that 1) the HRA was in existence prior to September 23, 2010, and 2) that the plan will experience a significant increase in premium or significant decrease in access to benefits if it complies with the restricted annual limits of the ACA. The language may be found in item five at the following URL: http://www.hhs.gov/ociio/regulations/patient/ociio_20101_20100903_508.pdf Please scan your signed attestation and attach it to an email to this address. If you cannot scan the attestation, please fax it to (301) 492-4217. If you will be faxing the attestation, please notify me first. In order to complete your application, please provide this information by 5:00 pm, December 10, 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. Kind Regards, Erika M. Kottenmeier Division of Enforcement Office of Oversight HHS/OCIIO erika.kottenmeier@hhs.gov

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file:///T|/...%20with%20NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Request%20for%20info%2012.9.10.htm[08/12/2011 3:51:06 PM]

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Seneca ARC:000004

From: Kottenmeier, Erika (HHS/OCIIO) Sent: Thursday, December 09, 2010 12:47 PM To: 'bkaminski@sencayarc.org' Cc: Habit, Sandra (HHS/OCIIO) Subject: Follow up to previous email

Document obtained by CompleteColorado.com

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

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extent of the law.

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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Dear Mr. Kaminski, In addition to the information requested in the previous email, your application is also missing a statement of how the application of the annual limits will result in a decrease in benefits to the HRA. The application must provide some evidence of how the annual limits will result in a significant increase in premiums (generally demonstrated by a percent increase), or a decrease in access to benefits. Without a statement of either we cannot grant the waiver. We are aware that HRAs are not typical health plans with premiums paid, so you will most likely have to make a showing of decrease in benefits. Please provide this information as well. Kind Regards, Erika M. Kottenmeier Division of Enforcement Office of Oversight HHS/OCIIO (301) 492-4170 erika.kottenmeier@hhs.gov

file:///T|/...2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Follow%20up%20to%20previous%20email%2012.9.10.htm[08/12/2011 3:51:06 PM]

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Seneca ARC:000005

From: Kottenmeier, Erika (HHS/OCIIO) Sent: Monday, December 13, 2010 11:27 AM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Annual Limits Waiver Application

Document obtained by CompleteColorado.com

-----Original Message----From: Kottenmeier, Erika (HHS/OCIIO) Sent: Monday, December 13, 2010 11:25 AM To: 'Bill Kaminski' Subject: RE: Annual Limits Waiver Application Dear Mr. Kaminski,

Kind Regards, Erika Kottenmeier -----Original Message----From: Bill Kaminski [mailto:bkaminski@sencayarc.org] Sent: Friday, December 10, 2010 2:49 PM To: Kottenmeier, Erika (HHS/OCIIO) Subject: Re: Annual Limits Waiver Application

Dear Erika, The lettered we mailed on 11/24/10 (signed copy attached) has the number of participants and dependents covered, etc...? I believe the letter and plan document answers the questions below? We sent this as an email and we mailed a hard-copy. Please review and let me know what else is required. Thanks. Bill Kaminski On 9 Dec 2010 at 12:24, Kottenmeier, Erika (HHS/OCIIO) wrote: > > Dear Mr. Kaminski, > > Thank you for your application on behalf of Seneca Cayuga ARCs > Standalone HRA. Before we can complete processing your application, we need several items of information from you. > Specifically, please provide the following: > > * The number of enrollees in the plan (including dependents) > * The amount the employer contributes to each employee > * A signed attestation as it is stated in the September 3, 2010 OCIIO Sub-Regulatory > guidance. The attestation must include a statement that 1) the HRA was in existence prior > to September 23, 2010, and 2) that the plan will experience a significant increase in > premium or significant decrease in access to benefits if it complies with the restricted annual > limits of the ACA. The language may be found in item five at the following URL: > > http://www.hhs.gov/ociio/regulations/patient/ociio_2010-1_20100903_508 > .pdf

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Seneca ARC:000006

file:///T|/...NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Request%20for%20info%20response%2012.13.10.txt[08/12/2011 3:51:06 PM]

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Thank you for your reply. Your cover letter was somehow separated from your plan documents, so I appreciate your re-sending it. However, we are still missing the employer contribution information, as it is not included in the Plan Document (it says $XXX.XX in place of a dollar amount). When we have that information your application will be complete.

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Document obtained by CompleteColorado.com > > Please scan your signed attestation and attach it to an email to this > address. If you cannot scan the attestation, please fax it to (301) > 492-4217. If you will be faxing the attestation, please notify me > first. In order to complete your application, please provide this > information by 5:00 pm, December 10, 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. > > Kind Regards, > > Erika M. Kottenmeier > Division of Enforcement > Office of Oversight > HHS/OCIIO > erika.kottenmeier@hhs.gov > > > 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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file:///T|/...NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Request%20for%20info%20response%2012.13.10.txt[08/12/2011 3:51:06 PM]

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Seneca ARC:000007

From: Kottenmeier, Erika (HHS/OCIIO) Sent: Monday, December 13, 2010 3:53 PM To: 'Bill Kaminski' Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: Annual Limits Waiver Application Mr. Kaminski;

Document obtained by CompleteColorado.com

No problem at all. Now I have all the information I need. I will make a recommendation to HHS leadership at the next possible opportunity. Thank you for your assistance. Best, Erika Kottenmeier -----Original Message----From: Bill Kaminski [mailto:bkaminski@sencayarc.org] Sent: Monday, December 13, 2010 3:35 PM To: Kottenmeier, Erika (HHS/OCIIO) Subject: RE: Annual Limits Waiver Application

Krika - sorry about the XXX.XX I missed that. The normal annual contribution has been $Ex. 4 per year. thanks. Bill k On 13 Dec 2010 at 11:24, Kottenmeier, Erika (HHS/OCIIO) wrote: From: "Kottenmeier, Erika (HHS/OCIIO)" <Erika.Kottenmeier@hhs.gov> To: 'Bill Kaminski' <bkaminski@sencayarc.org> Date sent: Mon, 13 Dec 2010 11:24:43 -0500 Subject: RE: Annual Limits Waiver Application

> Dear Mr. Kaminski, > > Thank you for your reply. Your cover letter was somehow separated from your plan documents, so I appreciate your re-sending it. However, we are still missing the employer contribution information, as it is not included in the Plan Document (it says $XXX.XX in place of a dollar amount). When we have that information your application will be complete. > > Kind Regards, > Erika Kottenmeier > > -----Original Message----> From: Bill Kaminski [mailto:bkaminski@sencayarc.org] > Sent: Friday, December 10, 2010 2:49 PM > To: Kottenmeier, Erika (HHS/OCIIO) > Subject: Re: Annual Limits Waiver Application > > Dear Erika, The lettered we mailed on 11/24/10 (signed copy attached) has the number of > participants and dependents covered, etc...? I believe the letter and plan document answers > the questions below? We sent this as an email and we mailed a hard-copy. Please review > and let me know what else is required. Thanks. Bill Kaminski > > On 9 Dec 2010 at 12:24, Kottenmeier, Erika (HHS/OCIIO) wrote:

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Seneca ARC:000008

file:///T|/...lications%20with%20NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Correspondence%2012.13.10.txt[08/12/2011 3:51:07 PM]

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Document obtained by CompleteColorado.com > >> > > Dear Mr. Kaminski, >> > > Thank you for your application on behalf of Seneca Cayuga ARCs Standalone HRA. Before we > > can complete processing your application, we need several items of information from you. > > Specifically, please provide the following: >> > > * The number of enrollees in the plan (including dependents) > > * The amount the employer contributes to each employee > > * A signed attestation as it is stated in the September 3, 2010 OCIIO Sub-Regulatory > > guidance. The attestation must include a statement that 1) the HRA was in existence prior > > to September 23, 2010, and 2) that the plan will experience a significant increase in > > premium or significant decrease in access to benefits if it complies with the restricted annual > > limits of the ACA. The language may be found in item five at the following URL: > > http://www.hhs.gov/ociio/regulations/patient/ociio_2010-1_20100903_508.pdf >> > > Please scan your signed attestation and attach it to an email to this address. If you cannot scan > > the attestation, please fax it to (301) 492-4217. If you will be faxing the attestation, please notify > > me first. In order to complete your application, please provide this information by 5:00 pm, > > December 10, 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. >> > > Kind Regards, >> > > Erika M. Kottenmeier > > Division of Enforcement > > Office of Oversight > > HHS/OCIIO > > erika.kottenmeier@hhs.gov >> >> > > 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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file:///T|/...lications%20with%20NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Correspondence%2012.13.10.txt[08/12/2011 3:51:07 PM]

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Seneca ARC:000009

From: Habit, Sandra (HHS/OCIIO) Sent: Thursday, December 30, 2010 5:39 PM To: 'bkaminski@sencayarc.org' Subject: Seneca Cayuga ARC 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 Seneca Cayuga ARC. 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,
Sandy Habit Department of Health and Human Services Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@hhs.gov

Document obtained by CompleteColorado.com

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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Seneca ARC:000010

file:///T|/...RC%20Approval%20Letter%20for%20a%20Waiver%20of%20the%20Annual%20Limits%20Requirements%2012-30-2010.htm[08/12/2011 3:51:07 PM]

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Document obtained by CompleteColorado.com

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Seneca ARC:000011

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Document obtained by CompleteColorado.com

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Seneca ARC:000012

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From: Bill Kaminski [bkaminski@sencayarc.org] Sent: Monday, January 03, 2011 2:59 PM To: Habit, Sandra (HHS/OCIIO) Subject: Re: Seneca Cayuga ARC Approval Letter for a Waiver of the Annual Limits Requirements 12-30-2010

Document obtained by CompleteColorado.com

Received your approval - thank you! Bill Kaminski, Seneca Cayuga ARC On 30 Dec 2010 at 17:38, Habit, Sandra (HHS/OCIIO) wrote: > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > Good Afternoon, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for Seneca Cayuga ARC. 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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Seneca ARC:000013

file:///T|/...ations%20with%20NO%2012600%20Response%20[YELLOW]/Seneca%20Cayuga%20ARC/Approval%20receipt%201.3.11.txt[08/12/2011 3:51:07 PM]

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