From: Kristie Watrous [kwatrous@mountainlakeservices.

org] Sent: Wednesday, November 17, 2010 4:03 PM To: HHS HealthInsurance (HHS) Subject: Waiver Follow Up Flag: Follow up Flag Status: Red Attachments: Mntn Lake Srvc Standalone HRA 1-1-10_SIGNED.pdf; SMM - Standalone HRA.pdf; SCAN5003_000.pdf Attached is Mountain Lake Services Waiver Application Letter with attachments. Please contact our office with any questions. Thank you.
Kristie Watrous Human Resources Specialist 546-7721

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ESSEX NYSARC:000001

file:///T|/...ng%20Team/Jean/Essex%20County%20Chapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Waiver.htm[12/21/2011 12:58:51 PM]

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Ex. 4 Ex. 4

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Ex. 4

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ESSEX NYSARC:000002

Pages 3 through 18 redacted for the following reasons: ---------------------------Exemption 4

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ESSEX NYSARC:000003

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From: Habit, Sandra (HHS/OCIIO) Sent: Wednesday, November 24, 2010 11:21 AM To: 'mnephew@mountainlakeservices.org' Subject: Waiver Application - Mountain Lake Services Mr. Nephew,

Sandra Habit Quality Analyst Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@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 disclosures may result in prosecution to the full extent
ESSEX NYSARC:000004

file:///T|/...pter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20additional%20info%2011.24.10.htm[12/21/2011 12:58:53 PM]

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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 regarding Mountain Lake Services: 1. Indicate the annual limit of the HRA. 2. Is this a self or fully insured policy? 3. Is this a group or individual policy? 4. Can you provide COBRA equivalent rates for the following chart: (The premium amounts is the total cost to the employer and the employee) Premium Premium Premium % increase if the (current level) (renewal) (if $750,000 $750,000 was annual limit was implemented 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) If you have any questions, please feel free to contact me. Have a good holiday! Thank you, Sandy

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of the law.

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ESSEX NYSARC:000005

file:///T|/...pter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20additional%20info%2011.24.10.htm[12/21/2011 12:58:53 PM]

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From: Marty Nephew [mnephew@mountainlakeservices.org] Sent: Wednesday, December 01, 2010 2:11 PM To: Habit, Sandra (HHS/OCIIO) Cc: Patricia Allen Subject: RE: Waiver Application - Mountain Lake Services

Ms. Habit, Please see responses below and let me know should you have any questions. Thank you,

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 regarding Mountain Lake Services: Ex. 4 1. Indicate the annual limit of the HRA. B n SPD for 2011 Annual Contributi plus Ex. 4 unused funds rolled from prior years. mum projected account rollover is $ e Ex. 4 maximum projected benefit would be $ . 2. Is this a self or fully insured policy? Se 3. Is this a group or individual policy? Gr 4. Can you provide COBRA equivalent rates for the following chart: (The premium amounts is the total cost to the employer and the employee) Premium Premium Premium % increase if the (current level) (renewal) (if $750,000 $750,000 was annual limit was implemented EE

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Ex. 4

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From: Habit, Sandra (HHS/OCIIO) [mailto:Sandra.Habit@hhs.gov] Sent: Wednesday, November 24, 2010 11:21 AM To: Marty Nephew Subject: Waiver Application - Mountain Lake Services

file:///T|/...hapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20info%20response%2012.1.10.htm[12/21/2011 12:58:54 PM]

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Martin J. Nephew Executive Director Mountain Lake Services 10 St. Patrick's Place Port Henry, NY 12974 Phone: (518)546-3381 x51 Fax: (518)546-7138

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Ex. 4

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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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Sandra Habit Quality Analyst Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@hhs.gov

EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier) If you have any questions, please feel free to contact me. Have a good holiday! Thank you, Sandy

file:///T|/...hapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20info%20response%2012.1.10.htm[12/21/2011 12:58:54 PM]

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ESSEX NYSARC:000007

From: Marty Nephew [mnephew@mountainlakeservices.org] Sent: Friday, December 03, 2010 7:17 AM To: Habit, Sandra (HHS/OCIIO) Subject: RE: Waiver Application - Mountain Lake Services
Sandy, This plan does comply with grandfathered regulations. Thanks,

Ms. Habit, Please see responses below and let me know should you have any questions. Thank you,

Martin J. Nephew Executive Director

ESSEX NYSARC:000008

file:///T|/...hapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20info%20response%2012.3.10.htm[12/21/2011 12:58:54 PM]

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From: Marty Nephew [mailto:mnephew@mountainlakeservices.org] Sent: Wednesday, December 01, 2010 2:11 PM To: Habit, Sandra (HHS/OCIIO) Cc: Patricia Allen Subject: RE: Waiver Application - Mountain Lake Services

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Mr. Nephew, Thank you for your response. I have one last question for you and then I should be finished reviewing your application. Is this plan complying with grandfathered regulations or in effect prior to March 23, 2010? Sandy

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From: Habit, Sandra (HHS/OCIIO) [mailto:Sandra.Habit@hhs.gov] Sent: Wednesday, December 01, 2010 2:17 PM To: Marty Nephew Cc: Patricia Allen Subject: RE: Waiver Application - Mountain Lake Services

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Martin J. Nephew Executive Director Mountain Lake Services 10 St. Patrick's Place Port Henry, NY 12974 Phone: (518)546-3381 x51 Fax: (518)546-7138

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Mountain Lake Services 10 St. Patrick's Place Port Henry, NY 12974 Phone: (518)546-3381 x51 Fax: (518)546-7138
From: Habit, Sandra (HHS/OCIIO) [mailto:Sandra.Habit@hhs.gov] Sent: Wednesday, November 24, 2010 11:21 AM To: Marty Nephew Subject: Waiver Application - Mountain Lake Services

EE

Ex. 4

EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier) If you have any questions, please feel free to contact me. Have a good holiday! Thank you, Sandy

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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 regarding Mountain Lake Services: Ex. 4 1. Indicate the annual limit of the HRA. B n SPD for 2011 Annual Contributi plus Ex. 4 unused funds rolled from prior years. mum projected account rollover is $ e Ex. 4 maximum projected benefit would be $ . 2. Is this a self or fully insured policy? Se 3. Is this a group or individual policy? Gr 4. Can you provide COBRA equivalent rates for the following chart: (The premium amounts is the total cost to the employer and the employee) Premium Premium Premium % increase if the (current level) (renewal) (if $750,000 $750,000 was annual limit was implemented

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file:///T|/...hapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20info%20response%2012.3.10.htm[12/21/2011 12:58:54 PM]

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Mr. Nephew,

ESSEX NYSARC:000009

Sandra Habit Quality Analyst Office of Consumer Information and Insurance Oversight 301-492-4175 Sandra.Habit@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 disclosures may result in prosecution to the full extent of the law.

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ESSEX NYSARC:000010

file:///T|/...hapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Request%20for%20info%20response%2012.3.10.htm[12/21/2011 12:58:54 PM]

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From: Botwinick, Alexandra (HHS/OCIIO) Sent: Tuesday, December 14, 2010 12:14 PM To: 'mnephew@mountainlakeservices.org' Subject: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High Follow Up Flag: Follow up Flag Status: Red 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 Mountain Lake Services. 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, Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

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file:///T|/...NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Mountain%20Lake%20Services%20approval%2012_14_10.htm[12/21/2011 12:58:55 PM]

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ESSEX NYSARC:000011

From: Marty Nephew [mnephew@mountainlakeservices.org] Sent: Tuesday, December 14, 2010 1:13 PM To: Botwinick, Alexandra (HHS/OCIIO) Subject: RE: Waiver of the Annual Limits Requirements of PHS Act Section 2711
Received on 12/12/2010. Thank you,

Alexandra Botwinick Office of Oversight HHS/OCIIO

alexandra.botwinick@hhs.gov

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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 Mountain Lake Services. 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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From: Botwinick, Alexandra (HHS/OCIIO) [mailto:Alexandra.Botwinick@hhs.gov] Sent: Tuesday, December 14, 2010 12:14 PM To: Marty Nephew Subject: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High

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Martin J. Nephew Executive Director Mountain Lake Services 10 St. Patrick's Place Port Henry, NY 12974 Phone: (518)546-3381 x51 Fax: (518)546-7138

file:///T|/...hapter%20NYSARC,%20Inc.%20dba%20Moutain%20Lake%20Services/Confirmation%20of%20Approval%2012-14-2010.htm[12/21/2011 12:58:56 PM]

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