Request for Waiver from the Restricted Annual Limits

The UFCW Local 1000 and Kroger Dallas Health and Welfare Plan, also known as MED 1000, seeks a waiver from the Restricted Annual Limits set forth in the interim final regulations. MED 1000 is a selfinsured Taft-Hartley employee benefit fund established as the result of collective bargaining between the United Food and Commercial Workers Local 1000(UFCW Local 1000) and the Kroger Company to provide basic health care benefits for the non-supervisory employees, represented by UFCW Local 1000, working in the retail grocery stores operated by the Kroger Company in Texas. These employees include bakery, deli, produce, grocery, pharmacy and front-end department employees and clerk employees engaged in the selling of merchandise or performing services incidental thereto. This waiver is sought because compliance with the restricted annual limit provision of the interim final regulations would significantly increase premiums and would result in a significant decrease in access to benefits for those currently covered by the Plan. The employer contribution is fixed by the terms of a Collective Bargaining Agreement and cannot be increased during the term of that Agreement. The expiration date of the current agreement is Ex. D4

Attached as Exhibit 1 Summary Plan Description Attached as Exhibit 2 Benefit Highlights

2. The number of individuals covered by the Plan Approximately 6

Ex. 4

Medical benefits annual limits Plan AA Plan A Plan B Plan C Plan D $Ex. 4 $ $ $ $

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3. The annual limits and rates applicable to the Plan Eligibility Requirements
Ex. 4

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mployees and dependents

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1. Terms of the Plan for which a waiver is sought

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UFCW L1000 Kroger:000001

Monthly contribution, or premium, rates are set forth in the Collective Bargaining Agreement. The employer contributes approximately Ex. 93% he premi ums, while the employees share is approximately 4 Ex. %. 4 The contribution or premium rates also cover the cost of Life Insurance, Disability, Dental and Vision Care benefits. 4. Description of why compliance with the interim final regulations would result in significant increase in premiums. In order to increase the maximum annual benefit limit for this self insured plan to $750,000 and to prudently plan for potential large claim activity, reinsurance or stop loss coverage would have to be purchased. A representative Specific and Aggregate Stop Loss bid from HCC Life has the following cost factors: $200,000 Specific Stop Loss Deductible annual premium Additional Self Funded Liability for coverage under the $200,000 Specific Deductible Total Additional 2011 Medical Cost
Ex. 4 The expected 2010 medical benefit cost is expected to total $14,

The increase cost would be approximately Ex. 36% 4

Ex. 4

,31

If any additional information is needed in order to process and grant this waiver request please contact the undersigned. Thank you for your consideration in this matter.

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Because the employer contribution is determined by the Collective Bargaining Agreement, the additional premiums would have to come from the employees. This would create a hardship for the Ex. 4 Ex. 4 employees, most of who earn between $7.50 12.0 per hour. It is likely that many employees would opt out of coverage because of the necessary premium increase, thus resulting in a significant decrease in access to benefits for those currently covered by the Plan.

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/$Ex. 4 ).

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$Ex. 4 $ $5,313

UFCW L1000 Kroger:000002

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Exhibit 1

Pages 4 through 77 redacted for the following reasons: ---------------------------Exemption 4

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From: Brian D Peters [bpeters@neba-fl.com] Sent: Tuesday, October 26, 2010 2:45 PM To: HHS HealthInsurance (HHS) Subject: Waiver Attachments: MED_1000_Waiver_Request.pdf; MED_1000_SPD_with_SMM.pdf; MED_1000_Benefit_Highlights.pdf

Dear Mr. James Mayhew, The United Food and Commercial Workers Local 1000 and Kroger Dallas Health & Welfare Plan is requesting a waiver from the restricted annual limits set forth in the interim final regulations. We have attached for your review: 1. Waiver Request

If you need any additional information, please feel free to contact me. Regards, Brian D Peters Fund Administrator

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Brian D. Peters, C.P.A. Vice President & Chief Information Officer NEBA, Inc. 2010 N. W. 150th Avenue Suite 100 Pembroke Pines, Florida 33028 800.842.5899 Toll Free 954.266.6322 954.266.2079 Fax Important Warning: This e-mail, and any attachments thereto, is intended only for use by the addressee(s) named herein and may contain legally privileged and/or confidential information. If you are not the intended recipient of this e-mail (or the person responsible for delivering this document to the intended recipient), you are hereby notified that any dissemination, distribution, printing or coping of this e-mail, and any attachment thereto, is strictly prohibited. If you have received this e-mail in error, please respond to the individual sending the message, and permanently delete the original and any copy of the e-mail and printout thereof.

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2. Summary Plan Description of the Fund 3. Benefit Highlights

From: Keels, Lisa (HHS/OCIIO) Sent: Friday, November 05, 2010 10:29 AM To: Brian D Peters Cc: 'Jim Crump'; Habit, Sandra (HHS/OCIIO) Subject: RE: UCFW Local 1000 Oklahoma Fund Waiver Application
Hi Brian, It was a pleasure speaking with you this morning as well. Please send any additional documents for UFCW Local 1000 and Kroger Dallas Health & Welfare Plan to the HHS general email, so we can ensure it goes through the entire process. Also, thank you and Jim for confirming that you plan to remove the $Ex. 4 lifetime limit on alcohol and substance abuse treatment. Thank you also for confirming that, if the annual limit requirements are waived for Plan AA, Plan A, and Plan B, the only annual limits you plan to have in the next Plan year are the overall annual limit and the annual limit on prescriptions. Please confirm via email that this is the case. Thank you again, and have a wonderful weekend. Regards, Lisa

Hi Lisa, It was a pleasure speaking with you this morning. In the call I referenced a waiver that was filed on another fund we administer. The waiver was emailed on Tuesday 10/26/2010 for the United Food and Commercial Workers Local 1000 and Kroger Dallas Health & Welfare Plan. If I need to send any additional information should I send it to you or the generic HHS email? We were preparing additional information for that Plan based on the additional information you requested for the Oklahoma Fund. Also, for your reference listed below is the contact information for the Fund Consultant. Please let me know if you need any additional information. Thanks, Brian Fund Consultant James H. Crump Crump Consulting, Inc. (913) 599-3822 jhcrump@everestkc.net From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Friday, October 29, 2010 4:12 PM To: Brian D Peters Subject: RE: UCFW Local 1000 Oklahoma Fund Waiver Application - Request for Additional Information

Thank you for the information, Mr. Peters. I will be in touch if I need additional information.
UFCW L1000 Kroger:000008

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From: Brian D Peters [mailto:bpeters@neba-fl.com] Sent: Friday, November 05, 2010 10:18 AM To: Keels, Lisa (HHS/OCIIO) Cc: 'Jim Crump' Subject: RE: UCFW Local 1000 Oklahoma Fund Waiver Application

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Enjoy your weekend. Thank you again, Lisa Keels

Brian D. Peters, C.P.A. Vice President & Chief Information Officer NEBA, Inc. 2010 N. W. 150th Avenue Suite 100 Pembroke Pines, Florida 33028 800.842.5899 Toll Free 954.266.6322 954.266.2079 Fax Important Warning: This e-mail, and any attachments thereto, is intended only for use by the addressee(s) named herein and may contain legally privileged and/or confidential information. If you are not the intended recipient of this e-mail (or the person responsible for delivering this document to the intended recipient), you are hereby notified that any dissemination, distribution, printing or coping of this e-mail, and any attachment thereto, is strictly prohibited. If you have received this e-mail in error, please respond to the individual sending the message, and permanently delete the original and any copy of the e-mail and printout thereof.

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From: Keels, Lisa (HHS/OCIIO) Sent: Tuesday, November 30, 2010 11:28 AM To: Jim Crump; Brian D Peters Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local 1000 and Kroger Dallas Health and Welfare Plan (MED 1000)
Hello, Jim, I just checked on the status of the application, and we are still missing some information. In order to complete your application, please provide the following information: Please confirm that the effective date for the new plans will be January 1, 2011. Please confirm that the overall lifetime limits on the plans will be removed. Please confirm that the lifetime limits on alcohol and substance abuse treatment will be removed. Some of the annual limits in the cover letter differ from the annual limits in the Benefits Program document submitted. The annual limits with discrepancies are as follows: Cover Letter ann 1. Plan A: $Ex. 4 2. Plan B: $ 3. Plan C: $ 4. Plan D: $ Benefits Program 1. Plan A: $Ex. 4 2. Plan B: $ 3. Plan C: $ 4. Plan D: $ Please confirm w In your application, you state that approximately Ex. 4 employees and dependents are covered by the Plan. re covered in each particular plan (i.e., please break Please indicate how many employees and depend out the numbers for Plan AA, Plan A, Plan B, Plan Plan D). For each plan (i.e., Plan AA, Plan A, Plan B, Plan C, and Plan D), 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 for each plan: 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

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

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Good morning Lisa, Im seeking an update on the status of the Waiver Application. The application was emailed to HHS on October 26. Thanks for your help. Regards, Jim Crump Crump Consulting, Inc. (consultant for the Plan) 913-599-3822

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From: Jim Crump [mailto:jhcrump@everestkc.net] Sent: Tuesday, November 30, 2010 9:51 AM To: Keels, Lisa (HHS/OCIIO) Subject: FW: UFCW Local 1000 and Kroger Dallas Health and Welfare Plan (MED 1000)

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In order to complete your application, please provide this information as soon as possible, preferably by 5:00pm today. We look forward to receiving your completed application. Thank you, Lisa

UFCW L1000 Kroger:000011

From: Keels, Lisa (HHS/OCIIO) Sent: Tuesday, November 30, 2010 4:03 PM To: Brian D Peters Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local 1000 and Kroger Dallas Health and Welfare Plan (MED 1000)
Thank you, Brian. I will let you know if we need additional information. Regards, Lisa
From: Brian D Peters [mailto:bpeters@neba-fl.com] Sent: Tuesday, November 30, 2010 3:38 PM To: Keels, Lisa (HHS/OCIIO) Subject: RE: UFCW Local 1000 and Kroger Dallas Health and Welfare Plan (MED 1000)

From: Keels, Lisa (HHS/OCIIO) [mailto:Lisa.Keels@hhs.gov] Sent: Tuesday, November 30, 2010 11:28 AM To: Jim Crump; Brian D Peters Cc: Habit, Sandra (HHS/OCIIO) Subject: RE: UFCW Local 1000 and Kroger Dallas Health and Welfare Plan (MED 1000)

Hello, Jim, I just checked on the status of the application, and we are still missing some information. In order to complete your application, please provide the following information:
UFCW L1000 Kroger:000012

file:///T|/...%20NO%2012600%20Response%20[YELLOW]/UFCW%20Local%201000%20&%20Kroger/Correspondence%2011.30.10.htm[07/27/2011 3:02:00 PM]

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Brian D. Peters, C.P.A. Vice President & Chief Information Officer NEBA, Inc. 2010 N. W. 150th Avenue Suite 100 Pembroke Pines, Florida 33028 800.842.5899 Toll Free 954.266.6322 954.266.2079 Fax Important Warning: This e-mail, and any attachments thereto, is intended only for use by the addressee(s) named herein and may contain legally privileged and/or confidential information. If you are not the intended recipient of this e-mail (or the person responsible for delivering this document to the intended recipient), you are hereby notified that any dissemination, distribution, printing or coping of this e-mail, and any attachment thereto, is strictly prohibited. If you have received this e-mail in error, please respond to the individual sending the message, and permanently delete the original and any copy of the e-mail and printout thereof.

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Dear Ms. Keels, Attached is a response to your questions listed below from the fund consultant. Please let me know if you need any additional information. Regards, Brian

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For each plan (i.e., Plan AA, Plan A, Plan B, Plan C, and Plan D), 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 for each plan:

EE

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2010 January Premium (current level)

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Benefits Program annual limits: 1. Plan A: $Ex. 4 2. Plan B: $ 3. Plan C: $ 4. Plan D: $ Please confirm what the annual limits are for each of these plans. In your application, you state that approximately Ex. 4 employees and dependents are covered by the Plan. Please indicate how many employees and dependents are covered in each particular plan (i.e., please break out the numbers for Plan AA, Plan A, Plan B, Plan C, and Plan D).

2011 January Premium (renewal)

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 as soon as possible, preferably by 5:00pm today. We
UFCW L1000 Kroger:000013

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Please confirm that the effective date for the new plans will be January 1, 2011. Please confirm that the overall lifetime limits on the plans will be removed. Please confirm that the lifetime limits on alcohol and substance abuse treatment will be removed. Some of the annual limits in the cover letter differ from the annual limits in the Benefits Program document submitted. The annual limits with discrepancies are as follows: Cover Letter annual limits: 1. Plan A: $Ex. 4 2. Plan B: $ 3. Plan C: $ 4. Plan D: $

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

look forward to receiving your completed application. Thank you, Lisa From: Jim Crump [mailto:jhcrump@everestkc.net] Sent: Tuesday, November 30, 2010 9:51 AM To: Keels, Lisa (HHS/OCIIO) Subject: FW: UFCW Local 1000 and Kroger Dallas Health and Welfare Plan (MED 1000) Good morning Lisa, Im seeking an update on the status of the Waiver Application. The application was emailed to HHS on October 26. Thanks for your help. Regards, Jim Crump Crump Consulting, Inc. (consultant for the Plan) 913-599-3822

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From: Botwinick, Alexandra (HHS/OCIIO) Sent: Monday, December 06, 2010 9:14 AM To: 'bpeters@neba-fl.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 2711 for UFCW Local 1000 and Kroger Dallas Health and Welfare Plan. 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,

alexandra.botwinick@hhs.gov

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Alexandra Botwinick Office of Oversight HHS/OCIIO

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From: Brian D Peters [bpeters@neba-fl.com] Sent: Monday, December 06, 2010 9:59 AM To: Botwinick, Alexandra (HHS/OCIIO) Cc: OCIIO Oversight; 'Jim Crump'; 'Phil Siino' Subject: RE: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Follow Up Flag: Follow up Flag Status: Red
Good Morning, We are confirming receipt of the below email. Regards, Brian

Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section 2711 for UFCW Local 1000 and Kroger Dallas Health and Welfare Plan. 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,

UFCW L1000 Kroger:000016

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From: Botwinick, Alexandra (HHS/OCIIO) [mailto:Alexandra.Botwinick@hhs.gov] Sent: Monday, December 06, 2010 9:15 AM To: 'bpeters@neba-fl.com' Subject: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High

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Brian D. Peters, C.P.A. Vice President & Chief Information Officer NEBA, Inc. 2010 N. W. 150th Avenue Suite 100 Pembroke Pines, Florida 33028 800.842.5899 Toll Free 954.266.6322 954.266.2079 Fax Important Warning: This e-mail, and any attachments thereto, is intended only for use by the addressee(s) named herein and may contain legally privileged and/or confidential information. If you are not the intended recipient of this e-mail (or the person responsible for delivering this document to the intended recipient), you are hereby notified that any dissemination, distribution, printing or coping of this e-mail, and any attachment thereto, is strictly prohibited. If you have received this e-mail in error, please respond to the individual sending the message, and permanently delete the original and any copy of the e-mail and printout thereof.

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Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

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