Document obtained by CompleteColorado.

com

MENTOR
Network
O c t o b e r 19, 2 0 1 0

B u i l d i n g Relationsl-iips. E n h a n c i n g Lives. www.thementornetwoi-k.com

D e p a r t m e n t o f Health a n d H u m a n S e n / i c e s Office of C o n s u m e r Information a n d Insurance Oversight, Office of Oversight Attention: J a m e s Mayhew, R o o m 737-F-04 200 Independence Ave. S W W a s h i n g t o n , D.C. 2 0 2 0 1 S u b j e c t : Waiver Application: T h e Mentor Network - Limited Medical Plan D e a r Mr. M a y h e w :

T h i s letter s e r v e s a s o u r w r i t t e n application f o r w a i v e r f r o m t h e a n n u a l dollar limit r e q u i r e m e n t s u n d e r t h e Patient Protection a n d A f f o r d a b l e C a r e A c t ( P P A C A ) a s it pertains t o o u r s e l f - i n s u r e d limited m e d i c a l p l a n . T h i s application r e q u e s t s w a i v e r f o r t h e J a n u a r y 1 , 2 0 1 1 t h r o u g h D e c e m b e r 3 1 , 2 0 1 1 policy p e r i o d . WAIVER APPLICATION

B e l o w is o u r application p e r t h e t e r m s outlined in S e c t i o n III o f y o u r S e p t e m b e r 3, 2 0 1 0 m e m o .

T h e t e r m s of t h e p l a n o r p o l i c y f o r m ( s ) f o r w h i c h a w a i v e r is s o u g h t :

T h e M e n t o r N e t w o r k ' s limited benefit m e d i c a l plan is a d m i n i s t e r e d t h r o u g h United H e a l t h c a r e a n d t h e prescription d r u g plan is a d m i n i s t e r e d t h r o u g h C V S C a r e m a r k ( u n d e r t h e United H e a l t h c a r e policy # 7 1 5 1 9 )

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o n a s e l f - i n s u r e d basis. Policy t e r m s a r e J a n u a r y 1 t h r o u g h D e c e m b e r 3 1 .

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T h e plan is o f f e r e d t o all b e n e f i t s eligible e m p l o y e e s ( e m p l o y e e s w o r k i n g o v e r

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Ex. 4

M e n t o r N e t w o r k ' s Direct S u p p o r t P r o f e s s i o n a l s ( D S P s ) a r e only a l l o w e d to enroll in t h e limited b e n e f i t plan d u r i n g their first y e a r o f e m p l o y m e n t b e f o r e having a c c e s s to t h e o t h e r t w o c o m p r e h e n s i v e p l a n s ( f o r 2 0 1 1 ,

$Ex. 4

A l l o t h e r e m p l o y e e s , N o n Direct S u p p o r t P r o f e s s i o n a l s ( N o n D S P s ) , c a n enroll in a n y p l a n

T h e n u m b e r of individuals c o v e r e d by the plan o r policy form(s) submitted:

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(including t h e limited benefit p l a n ) .

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t h e r e is a H D H P a n d a P P O p l a n ) . T h e a v e r a g e a n n u a l p a y f o r a benefits eligible D S P in J a n u a r y 2 0 1 0 w a s

A s of September 2010, there w e r e employees,

Ex. 4

Ex. 4

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Ex. 4 Ex. 4

hours a week). T h e

e m p l o y e e s enrolled in t h e limited benefit p l a n , O f t h e are DSPs. Of the DSPs,

Ex. 4

a r e N o n D S P s a n d Ex. 4

a r e D S P s within their first

year of service with no other medical option available from T h e Mentor Network.

T h e a n n u a l limit(s) a n d r a t e s a p p l i c a b l e to t h e p l a n o r p o l i c y f o r m ( s ) s u b m i t t e d :

313 Congress Street Sth Floor p. 617-790-4800

Boston M A 02210

f. 617-790-4848

Mentor:000001

O c t o b e r 19, 2 0 1 0 P a g e 2 of 5

Document obtained by CompleteColorado.com

T h e a n n u a l benefit limit is $
Ex. 4

Ex. 4

per c o v e r e d individual, w i t h a s e p a r a t e a n n u a l m a x i m u m of $
Ex. 4

Ex. 4

per

c o v e r e d individual for prescription d r u g s . W i t h i n the $ limit of $

a n n u a ! benefit limit t h e r e is a n a n n u a l benefit

Ex. 4

o n inpatient s e r v i c e s (excluding r o o m a n d b o a r d ) a n d a n a n n u a l benefit limit of $

Ex. 4

for

outpatient s e r v i c e s . T h e limited benefit plan c o v e r s preventive c a r e at Ex. 4 % up to $

per individual. T h e

plan also c o v e r s office visits, hospital c a r e , m e n t a l health, physical therapy, o u t p a t i e n t s e r v i c e s a n d prescription d r u g s . A s u m m a r y of benefits u n d e r the limited m e d i c a l plan is a t t a c h e d .

2 0 1 1 m o n t h l y p r e m i u m e q u i v a l e n t rates ( C O B R A rates m i n u s

% ) a r e a s follows:

Rate Tier E m p l o y e e Only Employee + 1 E m p l o y e e + Family

Total Premium
Ex. 4

A brief d e s c r i p t i o n of w l i y c o m p l i a n c e w i t h t h e interim final r e g u l a t i o n s w o u l d r e s u l t in a s i g n i f i c a n t d e c r e a s e in a c c e s s to b e n e f i t s for t h o s e c u r r e n t l y c o v e r e d by s u c h p l a n s or p o l i c i e s , o r s i g n i f i c a n t i n c r e a s e in p r e m i u m s paid by t h o s e c o v e r e d by s u c h p l a n s or p o l i c i e s , a l o n g w i t h a n y s u p p o r t i n g documentation:

T h e limited m e d i c a l plan is p r o v i d e d to all of T h e M e n t o r N e t w o r k ' s e m p l o y e e s . T h e D S P e m p l o y e e s c a n only enroll in the limited benefit plan d u r i n g their first y e a r of e m p l o y m e n t . T h e majority o f e m p l o y e e s enrolled in the limited benefit plan a r e D S P e m p l o y e e s . T h e s e e m p l o y e e s a r e low w a g e e a r n e r s . C o m p l i a n c e w i t h the interim final r e g u l a t i o n s w o u l d c a u s e the c o s t of c o v e r a g e to rise significantly t h e r e b y increasing the financial b u r d e n to T h e M e n t o r N e t w o r k e m p l o y e e s (specifically the D S P s ) . A s a n e x a m p l e , if T h e M e n t o r N e t w o r k o f f e r s the c u r r e n t s e l f - f u n d e d H D H P or P P O plan ( w h i c h d o e s not h a v e a n y limits) to

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Ex. 4

D S P s , the e m p l o y e e - o n l y c o n t r i b u t i o n w o u l d i n c r e a s e by a p p r o x i m a t e l y

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tribution % and
Ex. 4 % ,

respectively.

Due

to the cost differential, it is highly unlikely that D S P s w o u l d enroll in the c o m p r e h e n s i v e plan e v e n if it w e r e

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approximately $
Ex. 4

m a d e available. For an e m p l o y e e c o v e r i n g his/her family, this w o u l d result in a n a n n u a l i n c r e a s e o f if e n r o l l e d in t h e H D H P a n d $ Ex. 4 if e n r o l l e d in the P P O plan. T h i s w o u l d likely lead

to a loss of a c c e s s to c o v e r a g e for D S P e m p l o y e e s . P l e a s e s e e exhibit b e l o w outlining t h e s p e c i f i c s .

Mentor:000002

O c t o b e r 19, 2 0 1 0 P a g e 3 of 5

Document obtained by CompleteColorado.com

2011 Premium Rates and Employee Contributions Monthly Employee % Increase Employee Contribution if Enroll in C o m p r e h e n s i v e $ Increase Employee C o n t r i b u t i o n if Enroll in

Monthly P P O Plan EE EE+1 F H D H P (witii HSA) EE EE+1 F B a s i c Plan EE EE+1 F

Ex. 4

I attest that T h e M e n t o r N e t w o r k ' s limited benefit plan w a s in f o r c e prior to S e p t e m b e r 2 3 , 2 0 1 0 , a n d t h a t t h e application of restricted a n n u a l limits ( i n c r e a s e the a n n u a l limit to $ 7 5 0 , 0 0 0 ) to this plan w o u l d result in a

paid by t h o s e c o v e r e d by s u c h plans o r policies.

W e h o p e that this letter p r o v i d e s the r e q u i r e d d o c u m e n t a t i o n for w a i v e r c o n s i d e r a t i o n . P l e a s e feel f r e e to c o n t a c t m e at (617) 7 9 0 - 4 9 3 8 or p a m e l a . s a n d e @ t h e m e n t o r n e t w o r k . c o m i f y o u h a v e a n y q u e s t i o n s o r n e e d

Sincerely,

P a m e l a L. S a n d e , S P H R Sr. Director, T o t a l R e w a r d s & H R S e r v i c e s Attachment

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additional i n f o r m a t i o n .

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significant d e c r e a s e in a c c e s s to benefits for t h o s e currently c o v e r e d o r a significant i n c r e a s e in p r e m i u m s

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Attestation:

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Mentor:000003

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Document obtained by CompleteColorado.com

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

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Document obtained by CompleteColorado.com

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Mentor:000005

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Document obtained by CompleteColorado.com

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Mentor:000006

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From: DuBose, Amy (formerly Guilmette) [Amy.DuBose@TheMentorNetwork.com] Sent: Thursday, October 21, 2010 11:27 AM To: HHS HealthInsurance (HHS) Cc: Greco, Terri; Sande, Pamela L.; jessica.l.smith@towerswatson.com Subject: waiver Attachments: Waiver Application The Mentor Network - Limited Medical Plan.pdf
To Whom It May Concern,
Please find attached the limited benefit plan waiver application letter for The Mentor Network. The original copy will be sent to you via USPS mail today. Please contact me if you have any questions. Amy DuBose 617-790-4849

Document obtained by CompleteColorado.com

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Notice: This email may contain privileged or confidential information and is for the sole use of the intended recipient(s). If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you.

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Mentor:000007

file:///T|/...-%20YELLOW/Applications%20with%20NO%2012600%20Response%20[YELLOW]/The%20Mentor%20Network/waiver.htm[08/02/2011 3:48:49 PM]

From: Keels, Lisa (HHS/OCIIO) Sent: Monday, November 15, 2010 1:33 PM To: amy.dubose@thementornetwork.com; pamela.sande@thementornetwork.com Cc: Habit, Sandra (HHS/OCIIO) Subject: The Mentor Network - Limited Medical Plan Waiver Application - Request for Additional Information
Dear Ms. DuBose and Ms. Sande: 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: In your application, you state that Ex. 4 employees are covered under the limited benefit plan. Please provide the number of individuals covered by the plan submitted. Please let us know whether this plan is a grandfathered plan. Thank you for the premium rates and information you submitted. Please also 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 (renewal) (if $750,000 annual (current level) 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 16, 2010. We look forward to receiving your completed application. Thank you, Lisa Keels Lisa M. Keels, J.D. U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office of Oversight lisa.keels@hhs.gov 301-492-4168

Document obtained by CompleteColorado.com

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Mentor:000008

file:///T|/...O%2012600%20Response%20[YELLOW]/The%20Mentor%20Network/Request%20for%20additional%20info%2011.15.10.htm[08/02/2011 3:48:50 PM]

From: Moultrie, Cam (HHS/OCIIO) Sent: Monday, November 15, 2010 8:30 PM To: Habit, Sandra (HHS/OCIIO) Subject: FW: Waiver Application for The Mentor Network - Limited Medical Plan

From: Moultrie, Cam (HHS/OCIIO) Sent: Monday, November 15, 2010 8:21 PM To: 'pamela.sande@thementornetwork.com' Subject: Waiver Application for The Mentor Network - Limited Medical Plan

Document obtained by CompleteColorado.com

2010 January Premium (current level)

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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: 2011 January Premium (renewal) 2011 January Premium (if $750,000 annual limit was applied)

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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 your application, you state that Ex. 4 employees are covered under your limited benefit plan. Please provide the number of individuals covered by the plan or policy forms submitted. Please confirm whether the plan is in compliance with the interim final regulations relating to grandfathered health plans.

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In order to complete your application, please provide this information by 5:00 pm, November 16, 2010. We look forward to receiving your completed application. Thank you.
Mentor:000009

file:///T|/...2600%20Response%20[YELLOW]/The%20Mentor%20Network/Request%20for%20additional%20info%2011.15.10%20(2).htm[08/02/2011 3:48:51 PM]

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Dear Ms. Sande: 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 confirm whether the plan has lifetime or annual limits on ambulatory, emergency, hospitalization, laboratory, pediatric, maternity/newborn, mental health/substance abuse, rehabilitative/devices, preventive/wellness, or prescription benefits and identify the corresponding limits.

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Document obtained by CompleteColorado.com 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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Mentor:000010

file:///T|/...2600%20Response%20[YELLOW]/The%20Mentor%20Network/Request%20for%20additional%20info%2011.15.10%20(2).htm[08/02/2011 3:48:51 PM]

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From: Keels, Lisa (HHS/OCIIO) Sent: Tuesday, November 16, 2010 4:39 PM To: Greco, Terri Cc: Sande, Pamela L.; Habit, Sandra (HHS/OCIIO); Moultrie, Cam (HHS/OCIIO) Subject: RE: The Mentor Network - Limited Medical Plan Waiver Application - Request for Additional Information
Thank you, Ms. Greco. I will let you know if we have additional questions. Also, we are aware that you received a separate email from Cam Moultrie last night. Please disregard that email we had a duplicate of your application in our system. Thank you again, Lisa
From: Greco, Terri [mailto:Theresa.Greco@TheMentorNetwork.com] Sent: Tuesday, November 16, 2010 4:34 PM To: Keels, Lisa (HHS/OCIIO) Cc: Sande, Pamela L.; Habit, Sandra (HHS/OCIIO) Subject: FW: The Mentor Network - Limited Medical Plan Waiver Application - Request for Additional Information Dear Ms. Keels: I am forwarding the answers to your questions on the behalf of Pam Sande. 1. The total number of individuals covered by the plan submitted in Ex. 4 2. Yes, this plan is grandfathered. 3. Premium rates reflected in the third column below reflect an annual limit of $750,000 and removal of additional internal plan caps.

Document obtained by CompleteColorado.com

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2010 January Premium (current level)

Ex. 4

2011 January Premium (renewal)

EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)

Please do not hesitate to contact me or Pam Sande if you have any additional questions or need any further data. Regards, Terri Greco Terri Greco
Mentor:000011

file:///T|/...cations%20with%20NO%2012600%20Response%20[YELLOW]/The%20Mentor%20Network/Correspondence%2011.16.10.htm[08/02/2011 3:48:51 PM]

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2011 January Premium (if $750,000 annual limit was applied)

Benefits Manager The MENTOR Network 313 Congress Street Boston, MA 02210 (617) 790-4203 (617) 790-4809 (fax) theresa.greco@thementornetwork.com

Document obtained by CompleteColorado.com

From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Monday, November 15, 2010 1:33 PM To: DuBose, Amy (formerly Guilmette); Sande, Pamela L. Cc: Habit, Sandra (HHS/OCIIO) Subject: The Mentor Network - Limited Medical Plan Waiver Application - Request for Additional Information

Dear Ms. DuBose and Ms. Sande: 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: In your application, you state that Ex. 4 employees are covered under the limited benefit plan. Please provide the number of individuals covered by the plan submitted. Please let us know whether this plan is a grandfathered plan. Thank you for the premium rates and information you submitted. Please also 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 (renewal) (if $750,000 annual (current level) 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 16, 2010. We look forward to receiving your completed application.

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Mentor:000012

file:///T|/...cations%20with%20NO%2012600%20Response%20[YELLOW]/The%20Mentor%20Network/Correspondence%2011.16.10.htm[08/02/2011 3:48:51 PM]

Document obtained by CompleteColorado.com Thank you, Lisa Keels Lisa M. Keels, J.D. U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office of Oversight lisa.keels@hhs.gov 301-492-4168

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Mentor:000013

file:///T|/...cations%20with%20NO%2012600%20Response%20[YELLOW]/The%20Mentor%20Network/Correspondence%2011.16.10.htm[08/02/2011 3:48:51 PM]

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Notice: This email may contain privileged or confidential information and is for the sole use of the intended recipient(s). If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you.

Please do not hesitate to contact me or Pam Sande if you have any additional questions or need any further data. Regards, Terri Greco Terri Greco Benefits Manager The MENTOR Network 313 Congress Street Boston, MA 02210 (617) 790-4203 (617) 790-4809 (fax) theresa.greco@thementornetwork.com

From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov]

Mentor:000014

file:///T|/...nse%20[YELLOW]/The%20Mentor%20Network/Request%20for%20Additional%20Information%20Response%2011.16.10.htm[08/02/2011 3:48:52 PM]

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EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)

Ex. 4

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2010 January Premium (current level)

2011 January Premium (renewal)

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Dear Ms. Keels: I am forwarding the answers to your questions on the behalf of Pam Sande. 1. The total number of individuals covered by the plan submitted in Ex. 4 2. Yes, this plan is grandfathered. 3. Premium rates reflected in the third column below reflect an annual limit of $750,000 and removal of additional internal plan caps.

From: Greco, Terri [Theresa.Greco@TheMentorNetwork.com] Sent: Tuesday, November 16, 2010 4:34 PM To: Keels, Lisa (HHS/OCIIO) Cc: Sande, Pamela L.; Habit, Sandra (HHS/OCIIO) Subject: FW: The Mentor Network - Limited Medical Plan Waiver Application - Request for Additional Information

Document obtained by CompleteColorado.com

2011 January Premium (if $750,000 annual limit was applied)

Sent: Monday, November 15, 2010 1:33 PM Document obtained by CompleteColorado.com To: DuBose, Amy (formerly Guilmette); Sande, Pamela L. Cc: Habit, Sandra (HHS/OCIIO) Subject: The Mentor Network - Limited Medical Plan Waiver Application - Request for Additional Information

Dear Ms. DuBose and Ms. Sande: 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: In your application, you state that Ex. 4 employees are covered under the limited benefit plan. Please provide the number of individuals covered by the plan submitted. Please let us know whether this plan is a grandfathered plan. Thank you for the premium rates and information you submitted. Please also 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 (renewal) (if $750,000 annual (current level) 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 16, 2010. We look forward to receiving your completed application. Thank you, Lisa Keels Lisa M. Keels, J.D. U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office of Oversight lisa.keels@hhs.gov 301-492-4168

Notice: This email may contain privileged or confidential information and is for the sole use of the intended recipient(s). If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this
Mentor:000015

file:///T|/...nse%20[YELLOW]/The%20Mentor%20Network/Request%20for%20Additional%20Information%20Response%2011.16.10.htm[08/02/2011 3:48:52 PM]

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Document obtained by CompleteColorado.com information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you.

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Mentor:000016

file:///T|/...nse%20[YELLOW]/The%20Mentor%20Network/Request%20for%20Additional%20Information%20Response%2011.16.10.htm[08/02/2011 3:48:52 PM]

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From: Moultrie, Cam (HHS/OCIIO) Sent: Wednesday, November 17, 2010 12:43 PM To: Keels, Lisa (HHS/OCIIO) Subject: FW: Waiver Application for The Mentor Network - Limited Medical Plan
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: Greco, Terri [mailto:Theresa.Greco@TheMentorNetwork.com] Sent: Tuesday, November 16, 2010 4:40 PM To: Moultrie, Cam (HHS/OCIIO) Cc: Sande, Pamela L. Subject: FW: Waiver Application for The Mentor Network - Limited Medical Plan

Document obtained by CompleteColorado.com

Dear Ms. Moultrie: I am responding to your questions on the behalf of Pam Sande.

3. Yes, this plan is grandfathered.

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4. Premium rates reflected in the third column below reflect an annual limit of $750,000 and removal of additional internal plan caps.

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1. The plan has a total annual limit of $Ex. 4 for medical plus an annual limit of $Ex. 4 for prescription drug coverage. There is a $Ex. 4 annual limit for preventive/wellness. Essential benefits such as outpatient services that include outpatient and ambulatory surgery is limited to a $Ex. 4 annual limit and inpatient care that includes inpatient surgery and ancillary services is limited to $Ex. 4 per annum. Mental Health/substance abuse limits are included in the $Ex. 4 and the $Ex. 4 limits mentioned above. 2. The total number of individuals covered by the plan submitted in Ex. 4 .

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EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)

Please do not hesitate to contact me or Pam Sande if you have any additional questions or need any further data.
Mentor:000017

file:///T|/...20Network/FW%20Waiver%20Application%20for%20The%20Mentor%20Network%20-%20Limited%20Medical%20Plan.htm[08/02/2011 3:48:52 PM]

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2010 January Premium (current level)

2011 January Premium (renewal)

Ex. 4

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2011 January Premium (if $750,000 annual limit was applied)

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7. 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

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5. In your application, you state that Ex. 4 employees are covered under your limited benefit plan. Please provide the number of individuals covered by the plan or policy forms submitted. 6. Please confirm whether the plan is in compliance with the interim final regulations relating to grandfathered health plans.

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(renewal)

Dear Ms. Sande: 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: 4. Please confirm whether the plan has lifetime or annual limits on ambulatory, emergency, hospitalization, laboratory, pediatric, maternity/newborn, mental health/substance abuse, rehabilitative/devices, preventive/wellness, or prescription benefits and identify the corresponding limits.

2011 January Premium

(current level)

EE EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or

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From: Moultrie, Cam (HHS/OCIIO) [mailto:Cam.Moultrie@hhs.gov] Sent: Monday, November 15, 2010 8:21 PM To: Sande, Pamela L. Subject: Waiver Application for The Mentor Network - Limited Medical Plan

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2011 January Premium (if $750,000 annual limit was applied)
Mentor:000018

Regards, Terri Greco Terri Greco Benefits Manager The MENTOR Network 313 Congress Street Boston, MA 02210 (617) 790-4203 (617) 790-4809 (fax) theresa.greco@thementornetwork.com

Document obtained by CompleteColorado.com

file:///T|/...20Network/FW%20Waiver%20Application%20for%20The%20Mentor%20Network%20-%20Limited%20Medical%20Plan.htm[08/02/2011 3:48:52 PM]

other appropriate tier)

Document obtained by CompleteColorado.com

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Notice: This email may contain privileged or confidential information and is for the sole use of the intended recipient(s). If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you.

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In order to complete your application, please provide this information by 5:00 pm, November 16, 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

Mentor:000019

file:///T|/...20Network/FW%20Waiver%20Application%20for%20The%20Mentor%20Network%20-%20Limited%20Medical%20Plan.htm[08/02/2011 3:48:52 PM]

From: Keels, Lisa (HHS/OCIIO) Sent: Wednesday, November 17, 2010 1:10 PM To: Habit, Sandra (HHS/OCIIO) Subject: The Mentor Network - correspondence attached

Document obtained by CompleteColorado.com

Attachments: FW: Waiver Application for The Mentor Network - Limited Medical Plan
Hi Sandy, Cam and I had the same applicant, and they responded to me yesterday. Cam just forwarded me the response she received. I guess it cant hurt to put this email on the shared drive as well. Thanks! Lisa M. Keels, J.D. U.S. Department of Health & Human Services Office of Consumer Information and Insurance Oversight Office of Oversight lisa.keels@hhs.gov 301-492-4168

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Mentor:000020

file:///T|/...0Response%20[YELLOW]/The%20Mentor%20Network/The%20Mentor%20Network%20-%20correspondence%20attached.htm[08/02/2011 3:48:52 PM]

From: Botwinick, Alexandra (HHS/OCIIO) Sent: Tuesday, November 23, 2010 9:59 AM To: 'amy.dubose@thementornetwork.com' Subject: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section for The Mentor Network. 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 address with a copy to OCIIOOversight@hhs.gov. Please let me know if I can be of further assistance. Sincerely,

Document obtained by CompleteColorado.com

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Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

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Mentor:000021

file:///T|/...%20NO%2012600%20Response%20[YELLOW]/The%20Mentor%20Network/Approval%20Letter%20sent%2011-23-2010.htm[08/02/2011 3:48:53 PM]

From: Greco, Terri [Theresa.Greco@TheMentorNetwork.com] Sent: Tuesday, November 23, 2010 11:27 AM To: Botwinick, Alexandra (HHS/OCIIO) Cc: DuBose, Amy (formerly Guilmette) Subject: FW: Waiver of the Annual Limits Requirements of PHS Act Section 2711 - The Mentor Network Follow Up Flag: Follow up Flag Status: Red
Dear Ms. Botwinick, I am replying on behalf of Amy Dubose. This email is to confirm receipt of the determination letter for our Waiver of the Annual Limits Requirement of the PHS Act Section for The Mentor Network. Thank you for sending our determination letter. Kind regards, Terri Greco Terri Greco Benefits Manager The MENTOR Network 313 Congress Street Boston, MA 02210 (617) 790-4203 (617) 790-4809 (fax) theresa.greco@thementornetwork.com From: DuBose, Amy (formerly Guilmette) Sent: Tuesday, November 23, 2010 10:36 AM To: Greco, Terri; Sande, Pamela L. Subject: FW: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High

Document obtained by CompleteColorado.com

Attachments: Updated Jan 1 Approval Letter .pdf

Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section for The Mentor Network. 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 address with a copy to OCIIOOversight@hhs.gov. Please let me know if I can be of further assistance. Sincerely,
Mentor:000022

file:///T|/...600%20Response%20[YELLOW]/The%20Mentor%20Network/Confirmation%20of%20Approval%20letter%2011-29-2010.htm[08/02/2011 3:48:53 PM]

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From: Botwinick, Alexandra (HHS/OCIIO) [mailto:Alexandra.Botwinick@hhs.gov] Sent: Tuesday, November 23, 2010 9:59 AM To: DuBose, Amy (formerly Guilmette) Subject: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High

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Document obtained by CompleteColorado.com

Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

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Mentor:000023

file:///T|/...600%20Response%20[YELLOW]/The%20Mentor%20Network/Confirmation%20of%20Approval%20letter%2011-29-2010.htm[08/02/2011 3:48:53 PM]

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Notice: This email may contain privileged or confidential information and is for the sole use of the intended recipient(s). If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you.