Self-Insured Employers: Approved Applications for Waiver of the Annual Limits Requirements January 6, 2012 This is a list of self-insured employers that have received waivers of the annual dollar limit requirements for group health plans offered to their employees. On September 3, 2010 the Centers for Medicare & Medicaid Services (CMS) announced the initial waiver process, allowing plans to receive a one year waiver for plan or policy years with a start date between September 23, 2010 and September 23, 2011. On June 17, 2011 , the Centers for Medicare & Medicaid Services (CMS) issued subsequent guidance to conclude the annual limits waiver process. This guidance allowed plans that received one year waivers to extend those waivers through 2013, contingent on applicants submitting annual information about their plan and complying with requirements to ensure that their enrollees understand the limits of their coverage. The June 17, 2011 guidance also allowed any plans that had not yet applied for a waiver under the initial waiver policy to apply for one, good through 2013. All applications were due September 22, 2011. The June 17, 2011 guidance leaves three categories of plans that applied for and received waivers: 1. Plans that received a one year waiver under the initial policy that also received an extension under the June 17, 2011 policy. 2. Plans that received a one year waiver under the initial policy that did not apply for an extension under the June 17, 2011 policy. 3. Plans that did not apply for a one year waiver under the initial policy but did apply for, and receive one, good through 2013, under the June 17, 2011 policy. To capture these three categories, the list below is separated into two sections. Section A includes every plan that received a one year waiver under the initial policy. Plans without an asterisk applied for, and received, an extension (category 1 from above). Plans with an asterisk did not apply for an extension (category 2 from above). Section B lists plans that did not apply for a one year waiver under the initial policy but did apply for, and received, a waiver good through 2013. (category 3 from above).
Transcript
Self-Insured Employers: Approved Applications for Waiver of the Annual Limits Requirements
January 6, 2012 This is a list of self-insured employers that have received waivers of the annual dollar limit requirements for group health plans offered to their employees.
On September 3, 2010 the Centers for Medicare & Medicaid Services (CMS) announced the initial waiver process, allowing plans to receive a one year waiver for plan or policy years with a start date between September 23, 2010 and September 23, 2011.
On June 17, 2011, the Centers for Medicare & Medicaid Services (CMS) issued subsequent guidance to conclude the annual limits waiver process. This guidance allowed plans that received one year waivers to extend those waivers through 2013, contingent on applicants submitting annual information about their plan and complying with requirements to ensure that their enrollees understand the limits of their coverage. The June 17, 2011 guidance also allowed any plans that had not yet applied for a waiver under the initial waiver policy to apply for one, good through 2013. All applications were due September 22, 2011.
The June 17, 2011 guidance leaves three categories of plans that applied for and received waivers:
1. Plans that received a one year waiver under the initial policy that also received an extension under the June 17, 2011 policy.
2. Plans that received a one year waiver under the initial policy that did not apply for an extension under the June 17, 2011 policy.
3. Plans that did not apply for a one year waiver under the initial policy but did apply for, and receive one, good through 2013, under the June 17, 2011 policy.
To capture these three categories, the list below is separated into two sections.
Section A includes every plan that received a one year waiver under the initial policy. Plans without an asterisk applied for, and received, an extension (category 1 from above). Plans with an asterisk did not apply for an extension (category 2 from above).
Section B lists plans that did not apply for a one year waiver under the initial policy but did apply for, and received, a waiver good through 2013. (category 3 from above).
Section A: Section A includes every plan that received a one year waiver under the initial policy. Plans with an asterisk did not apply for an extension. Plans without an asterisk applied for, and received, an extension. Plans must submit annual information about their plan and comply with requirements to ensure that their enrollees understand the limits of their coverage.
2 Baptist Retirement Homes of North Carolina Winston-Salem NC 9/10/2010 10/1/2010 127 9/17/2010 9/24/2010
3 Cryogenic Vessel Alternatives Inc. Mont Belvieu TX 9/20/2010 10/1/2010 19 9/20/2010 9/24/2010 4 Fowler Packing Co. Fresno CA 9/8/2010 10/1/2010 39 9/17/2010 9/24/2010 5 Guy C. Lee Building Materials* Smithfield NC 9/15/2010 10/1/2010 312 9/15/2010 9/24/2010 6 HealthPort Alpharetta GA 9/18/2010 10/1/2010 525 9/18/2010 9/24/2010 7 Jack in the Box, Inc. San Diego CA 9/17/2010 10/1/2010 1,117 9/21/2010 9/24/2010 8 Maverick County Houston TX 9/21/2010 10/1/2010 1 9/23/2010 9/24/2010 9 QK/DRD (Denny's) Scottsdale AZ 9/16/2010 10/1/2010 65 9/22/2010 9/24/2010
10 Tri-Pak Machinery, Inc. Harlingen TX 9/20/2010 10/1/2010 26 9/20/2010 9/24/2010 11 Sanderson Plumbing Products Inc. Columbus MS 9/22/2010 10/1/2010 326 9/22/2010 9/27/2010
12 Vernon Sheltered Workshop, Inc. Health and Welfare Plan #501 Leesville LA 9/16/2010 10/1/2010 41 9/16/2010 9/27/2010
13 Diversified Interiors Inc. El Paso TX 9/28/2010 10/1/2010 300 9/28/2010 10/1/2010 14 The Buccaneer, Inc. Christiansted VI 9/22/2010 10/1/2010 125 9/28/2010 10/1/2010 15 Belmont Village, L.P. Houston TX 9/10/2010 1/1/2011 785 10/4/2010 10/8/2010 16 Cracker Barrel Lebanon TN 9/9/2010 1/1/2011 16,823 9/17/2010 10/8/2010 17 Dish Network LLC Englewood CO 9/13/2010 3/1/2011 3,597 9/23/2010 10/8/2010 18 Groendyke Transport, Inc. Enid OK 9/2/2010 1/1/2011 1,322 9/10/2010 10/8/2010 19 Harden Healthcare Austin TX 9/9/2010 1/1/2011 847 9/9/2010 10/8/2010 20 Pocono Medical Center East Stroudsburg PA 9/24/2010 1/1/2011 3,298 9/24/2010 10/8/2010 21 Regis Corporation Minneapolis MN 9/10/2010 3/1/2011 3,617 10/8/2010 10/8/2010 22 The Brinkmann Corporation Dallas TX 9/29/2010 1/1/2011 163 10/4/2010 10/8/2010 23 The Pictsweet Company Nashville TN 9/13/2010 1/1/2011 694 9/13/2010 10/8/2010 24 AMF Bowling Worldwide Richmond VA 9/14/2010 1/1/2011 612 10/7/2010 10/12/2010 25 Assisted Living Concepts Nenomonee Falls WI 9/17/2010 1/1/2011 1,174 10/12/2010 10/12/2010 26 Case & Associates Tulsa OK 9/17/2010 1/1/2011 87 9/17/2010 10/12/2010 27 GPM Investments, LLC Richmond VA 9/17/2010 1/1/2011 275 10/7/2010 10/12/2010 28 Grace Living Centers Oklahoma City OK 9/14/2010 10/1/2010 534 9/14/2010 10/12/2010
29 Mountaire Corporation Employees Health and Welfare Trust Millsboro DE 9/10/2010 1/1/2011 1,200 9/10/2010 10/12/2010
30 Swift Spinning, Inc. Morgan City LA 9/16/2010 1/1/2011 240 9/16/2010 10/12/2010
89 GC Services, L.P. & First Community Bancshares, Inc. Houston TX 10/15/2010 1/1/2011 1,936 10/15/2010 11/5/2010
90 Guardsmark, LLC Memphis TN 10/4/2010 2/1/2011 8,086 10/29/2010 11/5/2010 91 Mars Super Markets Inc. Glen Burnie MD 10/8/2010 7/1/2011 174 10/29/2010 11/5/2010 92 MPS Group Inc. Melville NY 10/12/2010 1/1/2011 2,253 11/2/2010 11/5/2010
93 Noodles & Company Broomfield CO 10/1/2010 5/12/2011
1/1/2011 7/1/2011 316
10/29/2010 6/28/2011
11/5/2010 6/29/2011
94 Pharmaca Integrative Pharmacy Boulder CO 10/15/2010 1/1/2011 50 11/4/2010 11/5/2010 95 Quality Integrated Services, Inc. Oklahoma City OK 10/8/2010 1/1/2011 354 11/3/2010 11/5/2010 96 RE Rabalais Constructors, LTD Corpus Christi TX 10/13/2010 12/1/2010 70 11/1/2010 11/5/2010 97 Security Forces, Inc. Charlotte NC 10/12/2010 1/1/2011 225 11/1/2010 11/5/2010
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
98 Shirkey Nursing & Rehabiitation Center Richmond MO 9/30/2010 1/1/2011 205 10/26/2010 11/5/2010 99 Spindle Cooling & Warehouse San Luis AZ 10/5/2010 11/1/2010 89 10/27/2010 11/5/2010 100 Strauss Discount Auto* South River NJ 10/14/2010 1/1/2011 401 11/4/2010 11/5/2010 101 Sunburst Hospitality Silver Spring MD 9/30/2010 1/1/2011 197 11/4/2010 11/5/2010 102 Susser Holdings Corp Corpus Christi TX 10/6/2010 1/1/2011 4,245 10/6/2010 11/5/2010 103 Telescope Casual Furniture Granville NY 10/4/2010 10/1/2010 32 11/1/2010 11/5/2010 104 The LDF Companies Wichita KS 10/7/2010 1/1/2011 210 10/30/2010 11/5/2010 105 Valley Services, Inc. Jackson MS 10/8/2010 1/1/2011 927 10/29/2010 11/5/2010 106 A. Duda & Sons Inc. Oviedo FL 10/14/2010 1/1/2011 62 11/4/2010 11/15/2010 107 American Farms PRM Health Plan Salinas CA 10/21/2010 1/1/2011 163 10/21/2010 11/15/2010
108 American Growers Cooling PRM Health Plan Salinas CA 10/21/2010 1/1/2011 97 10/21/2010 11/15/2010
109 AUTO LP dba AutoInc. Health Benefit Plan Amarillo TX 10/20/2010 11/1/2010 145 11/9/2010 11/15/2010
110 Better Way Products LLC New Paris IN 10/4/2010 1/1/2011 93 11/9/2010 11/15/2010 111 Big Valley Labor PRM Health Plan Livingston CA 10/21/2010 1/1/2011 4 10/21/2010 11/15/2010 112 Carington Health System Hamilton OH 10/18/2010 1/1/2011 3,327 11/4/2010 11/15/2010 113 CB Harvesting PRM Health Plan Yuma AZ 10/21/2010 1/1/2011 62 10/21/2010 11/15/2010 114 City of Rockwall Rockwall TX 10/20/2010 1/1/2011 168 11/9/2010 11/15/2010 115 Club Chef LLC Covington KY 9/30/2010 1/1/2011 282 10/26/2010 11/15/2010 116 Cocopah Nurseries Inc. Thermal CA 10/26/2010 1/1/2011 75 11/10/2010 11/15/2010 117 CRST International Cedar Rapids IA 10/19/2010 1/1/2011 1,600 11/4/2010 11/15/2010 118 Express Harvesting PRM Health Plan Salinas CA 10/21/2010 1/1/2011 166 10/21/2010 11/15/2010 119 Fallen Oak Packing PRM Health Plan Salinas CA 10/21/2010 1/1/2011 37 10/21/2010 11/15/2010 120 Foot Locker Inc. New York NY 10/6/2010 1/1/2011 424 11/5/2010 11/15/2010 121 Fresh Express Cincinnati OH 10/18/2010 1/1/2011 2,033 11/7/2010 11/15/2010 122 G&H Farms, PRM Health Plan Salinas CA 10/21/2010 1/1/2011 146 10/21/2010 11/15/2010 123 Gill Ranch, PRM Health Plan Portland OR 10/21/2010 1/1/2011 157 10/21/2010 11/15/2010 124 Gill Transport, PRM Health Plan Fresno CA 10/21/2010 1/1/2011 67 10/21/2010 11/15/2010 125 Gills Onions, PRM Health Plan Oxnard CA 10/21/2010 1/1/2011 295 10/21/2010 11/15/2010
126 Green Valley Farm Supply, PRM Health Plan Gonzales CA 10/21/2010 1/1/2011 29 10/21/2010 11/15/2010
127 Greencroft Communities Goshen IN 9/28/2010 1/1/2011 150 10/22/2010 11/15/2010 128 Growers Express, PRM Health Plan Salinas CA 10/21/2010 1/1/2011 44 10/21/2010 11/15/2010 129 Hall Management Group, Inc. Morganton NC 9/30/2010 12/1/2010 226 11/8/2010 11/15/2010 130 IH Services, Inc. Greenville SC 10/19/2010 1/1/2011 292 11/5/2010 11/15/2010
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
131 Independent Group Home Living Program, Inc. Manorville NY 10/26/2010 1/1/2011 39 11/10/2010 11/15/2010
132 King City Nursery, PRM Health Plan King City CA 10/21/2010 1/1/2011 93 10/21/2010 11/15/2010
133 Knox County Association for Retarded Citizens* Vincennes IN 10/6/2010 1/1/2011 96 10/25/2010 11/15/2010
134 Meijer Health Benefits Plan/Primary Care Option Grand Rapids MI 10/22/2010 1/1/2011 7,436 10/25/2010 11/15/2010
135 Mission Ranches PRM Health Plan King City CA 10/21/2010 1/1/2011 368 10/21/2010 11/15/2010
136 Moore's Retread & Tire of the Ark-La-Tex, Inc. Shreveport LA 10/20/2010 11/1/2010 66 11/5/2010 11/15/2010
137 Nexion Health* Sykesville MD 10/21/2010 11/1/2010 1,449 11/3/2010 11/15/2010 138 Payroll Solutions* North Las Vegas NV 10/4/2010 1/1/2011 382 11/9/2010 11/15/2010 139 RREMC LLC Scottsdale AZ 10/12/2010 1/1/2011 62 11/4/2010 11/15/2010 140 Seco Packing PRM King City CA 10/21/2010 1/1/2011 104 10/21/2010 11/15/2010 141 TeleTech Holdings, Inc. Englewood CO 10/15/2010 1/1/2011 1,083 11/4/2010 11/15/2010 142 TransCorr* Indianapolis IN 10/15/2010 1/1/2011 578 11/8/2010 11/15/2010 143 Universal Orlando Orlando FL 10/15/2010 4/1/2011 668 11/3/2010 11/15/2010 144 Western Growers Assurance Trust Irvine CA 9/30/2010 7/1/2011 19,200 11/8/2010 11/15/2010 145 Advantage Benefits Company LLC Boca Raton FL 10/18/2010 12/1/2010 57 11/1/2010 11/23/2010 146 Altisource Portfolio Solutions Kennesaw GA 10/21/2010 1/1/2011 200 11/15/2010 11/23/2010 147 Americare Properties Inc. Topeka KS 11/12/2010 1/1/2011 547 11/12/2010 11/23/2010 148 APWU Health Plan Conversion Plan Glen Burnie MD 10/20/2010 1/1/2011 518 11/16/2010 11/23/2010 149 Aspen Skiing Company Aspen CO 10/27/2010 1/1/2011 376 11/10/2010 11/23/2010 150 Belk Farms Coachella CA 11/4/2010 1/1/2011 34 11/4/2010 11/23/2010
151 Catholic Charities of the Diocese of Ogdensburg Ogdensburg NY 10/28/2010 1/1/2011 30 11/17/2010 11/23/2010
152 Cotton Belt Inc. Mathews NC 10/28/2010 1/1/2011 34 11/15/2010 11/23/2010 153 First Acceptance Corporation Nashville TN 11/9/2010 7/1/2011 864 11/18/2010 11/23/2010 154 Fruhauf Uniforms Direct Labor Wichita KS 10/18/2010 1/1/2011 159 11/12/2010 11/23/2010 155 Golden State Bulb Growers, Inc. Moss Landing CA 10/6/2010 1/1/2011 300 11/17/2010 11/23/2010 156 Grower's Transport, LLC Thermal CA 10/26/2010 12/1/2010 25 11/15/2010 11/23/2010 157 Heartland Automotive Services, Inc. Irving TX 10/20/2010 1/1/2011 661 11/15/2010 11/23/2010
158 Hoosier Stamping and Manufacturing Corporation* Chandler IN 10/20/2010 1/1/2011 14 10/20/2010 11/23/2010
159 Horizon Bay Realty LLC Tampa FL 11/12/2010 4/1/2011 949 11/12/2010 11/23/2010 160 Ingomar Packing Company, LLC Los Banos CA 11/10/2010 1/1/2011 150 11/10/2010 11/23/2010 161 Max Homes LLC 10/27/2010 10/1/2010 759 11/11/2010 11/23/2010 162 Mesa Air Group Phoenix AZ 11/1/2010 4/1/2011 2,142 11/1/2010 11/23/2010
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
163 Mesa Packing King City CA 10/21/2010 1/1/2011 39 11/18/2010 11/23/2010 164 Mission Linen Supply Santa Barbara CA 11/5/2010 1/1/2011 541 11/17/2010 11/23/2010 165 NFI Industries Vineland NJ 10/26/2010 1/1/2011 945 11/18/2010 11/23/2010
166 Opportunity Resources Inc. Health and Welfare Plan Roanoke VA 11/2/2010 12/1/2010 27 11/2/2010 11/23/2010
167 Orscheln Industries Moberly MO 10/19/2010 1/1/2011 547 11/8/2010 11/23/2010 168 Pacific Risk Management Salinas CA 10/21/2010 1/1/2011 3 11/18/2010 11/23/2010 169 Pearson Candy Company St. Paul MN 10/27/2010 1/1/2011 204 11/12/2010 11/23/2010 170 Pinnacle PRM 10/21/2010 1/1/2011 58 11/18/2010 11/23/2010 171 Rancho Maria PRM* Santa Maria CA 10/21/2010 1/1/2011 28 11/18/2010 11/23/2010 172 Rio Farms PRM Oxnard CA 10/21/2010 1/1/2011 317 11/18/2010 11/23/2010 173 Sensient Technologies Corporation Milwaukee WI 10/28/2010 1/1/2011 94 11/17/2010 11/23/2010 174 SFN Group Ft Lauderdale FL 11/9/2010 5/1/2011 1,419 11/9/2010 11/23/2010 175 Sun Healthcare Group Inc. Irvine CA 10/21/2010 1/1/2011 2,200 11/15/2010 11/23/2010 176 Telesis Management Corporation Dallas TX 10/28/2010 1/1/2011 148 11/16/2010 11/23/2010 177 The Mentor Network Boston MA 10/21/2010 1/1/2011 6,843 11/16/2010 11/23/2010
178 The Wilks Group, Inc. dba Ashley Furniture Homestore College Station TX 11/12/2010 12/1/2010 8 11/12/2010 11/23/2010
179 Trans-System, Inc. Spokane WA 10/19/2010 12/1/2010 232 11/8/2010 11/23/2010
180 True Leaf Farms San Juan Bautista CA 10/21/2010 1/1/2011 139 11/18/2010 11/23/2010
181 Varsity Contractors Inc. Pocatello ID 11/8/2010 1/1/2011 198 11/8/2010 11/23/2010 182 Wada Farms, Inc. Pingree ID 11/10/2010 1/1/2011 130 11/10/2010 11/23/2010 183 Waffle House, Inc. Norcross GA 10/20/2010 6/1/2011 3,947 11/12/2010 11/23/2010 184 Western Express Inc. Nashville TN 11/5/2010 1/1/2011 1,287 11/5/2010 11/23/2010 185 Western Harvesting King City CA 10/21/2010 1/1/2011 28 11/18/2010 11/23/2010 186 World Class Automotive Garland TX 10/27/2010 1/1/2011 550 11/9/2010 11/23/2010
187 AJFC Community Action Agency Employee Medical Benefits Plan Natchez MS 10/13/2010 10/1/2010 215 11/8/2010 11/30/2010
188 AMN Healthcare San Diego CA 10/12/2010 1/1/2011 3,440 11/8/2010 11/30/2010 189 Baylor County Hospital District Seymour TX 10/20/2010 1/1/2011 208 11/12/2010 11/30/2010 190 Central Mills New York NY 10/19/2010 6/1/2011 300 11/10/2010 11/30/2010 191 Medical Development Corporation Atlanta GA 11/12/2010 1/1/2011 105 11/17/2010 11/30/2010 192 Progressive Logistics Services, LLC Atlanta GA 10/12/2010 1/1/2011 1,248 11/4/2010 11/30/2010 193 Weckworth Manufacturing, Inc. Haysville KS 11/12/2010 12/1/2010 65 11/12/2010 11/30/2010 194 Yukon-Kuskokwim Health Corporation 10/18/2010 1/1/2011 501 10/18/2010 11/30/2010 195 Goodwill Industries of Central Oklahoma Oklahoma City OK 11/17/2010 1/1/2011 83 11/17/2010 12/1/2010 196 Maple Knoll Communities Cincinnati OH 11/19/2010 1/1/2011 348 11/29/2010 12/1/2010
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
197 Marshall Durbin Food Corporation Birmingham AL 11/11/2010 1/1/2011 45 11/29/2010 12/1/2010 198 Regent Care Center Galveston TX 10/29/2010 1/1/2011 432 11/16/2010 12/1/2010 199 Rice Food Markets, Inc. Houston TX 11/1/2010 1/1/2011 202 11/18/2010 12/1/2010 200 The Talbots, Inc. Hingham MA 11/15/2010 1/1/2011 22 11/22/2010 12/1/2010 201 Town of Frisco Frisco CO 11/1/2010 1/1/2011 8 11/1/2010 12/1/2010 202 Tudor Ranch, Inc. Mecca CA 11/12/2010 1/1/2011 47 11/12/2010 12/1/2010
203 W.G. Yates and Sons Construction Company and Affiliated Companies Philadelphia MS 11/16/2010 1/1/2011 52 11/16/2010 12/1/2010
204 WageWorks, Inc.* San Mateo CA 11/9/2010 1/1/2011 50,000 11/24/2010 12/1/2010 205 Wright Travel Nashville TN 11/2/2010 1/1/2011 19 11/2/2010 12/1/2010 206 Act Trust Mini-Med Plan Birmingham AL 11/11/2010 1/1/2011 67 11/19/2010 12/6/2010 207 Allen's Family Food Seaford DE 10/25/2010 1/1/2011 885 11/17/2010 12/6/2010 208 Anderson Media Corporation Knoxville TN 10/28/2010 7/1/2011 1,941 11/19/2010 12/6/2010 209 Care Initiatives, Inc. West Des Moines IA 10/25/2010 8/1/2011 287 11/19/2010 12/6/2010
210 Civil Service Bar Association Security Benefit Fund White Planes NY 11/10/2010 1/1/2011 1,515 11/30/2010 12/6/2010
211 CPC Logistics Health & Welfare Plan* Chesterfield MO 11/3/2010 1/1/2011 5,815 11/29/2010 12/6/2010 212 Crystal Run Healthcare Middleton NY 11/1/2010 1/1/2011 315 11/23/2010 12/6/2010
213 Diamondback Management Services Ltd. San Antonio TX 10/25/2010 1/1/2011 367 11/19/2010 12/6/2010
214 Hardwick Clothes, Inc. Cleveland TN 11/3/2010 1/1/2011 264 11/22/2010 12/6/2010 215 Katy Industries, Inc. Bridgeton MO 10/28/2010 1/1/2011 191 10/28/2010 12/6/2010 216 M.A. Mortenson* Minneapolis MN 10/12/2010 1/1/2011 332 11/26/2010 12/6/2010 217 Name Brand Inc. Tulsa OK 10/18/2010 1/1/2011 33 11/23/2010 12/6/2010 218 PepsiCo Inc 11/8/2010 1/1/2011 301 12/3/2010 12/6/2010 219 Pure Air Filter Sales & Service Greenwood MS 11/8/2010 1/1/2011 136 11/8/2010 12/6/2010 220 Ricker Oil Company, Inc.* Anderson IN 11/5/2010 1/1/2011 102 11/22/2010 12/6/2010 221 Skilled Health Care Foothill Ranch CA 10/28/2010 1/1/2011 1,080 11/16/2010 12/6/2010 222 The Durango Herald Durango CO 10/13/2010 1/1/2011 55 11/17/2010 12/6/2010 223 Atlantis Casino Resort Spa Reno NV 11/4/2010 2/1/2011 16 11/22/2010 12/7/2010 224 Reiter Affiliated Companies Oxnard CA 11/10/2010 1/1/2011 2,474 11/19/2010 12/8/2010 225 The Louis Berger Group, Inc. Morristown NJ 11/19/2010 1/1/2011 311 12/1/2010 12/8/2010 226 WD Young & Son's, Inc. Indio CA 11/3/2010 1/1/2011 288 11/16/2010 12/8/2010 227 Andrews Transport L.P. Fort Worth TX 11/2/2010 9/1/2011 154 11/19/2010 12/9/2010 228 B. R. Company La Quinta CA 11/10/2010 1/1/2011 9 11/19/2010 12/9/2010 229 Britz Companies et al.* Fresno CA 11/4/2010 2/1/2011 531 12/7/2010 12/9/2010
243 Vestal Manufacturing Enterprises, Inc. Sweetwater TN 11/24/2010 1/1/2011 174 12/9/2010 12/10/2010 244 Vincent B Zaninovich & Sons Inc. Richgrove CA 11/17/2010 1/1/2011 2,288 11/17/2010 12/10/2010 245 EchoStar Englewood CO 11/8/2010 3/1/2011 156 11/8/2010 12/13/2010 246 The Chickasaw Nation Ada OK 11/22/2010 1/1/2011 3,736 12/13/2010 12/13/2010 247 Brock Enterprises, Inc. Beaumont TX 10/25/2010 3/1/2011 1,051 11/5/2010 12/14/2010 248 Donsco Inc. Wrightsville PA 11/19/2010 1/1/2011 20 12/14/2010 12/14/2010 249 Executive Management Services Inc. Indianapolis IN 11/18/2010 8/1/2011 161 11/29/2010 12/14/2010 250 Hacienda Harvesting, Inc. Santa Maria CA 11/10/2010 1/1/2011 118 12/7/2010 12/14/2010 251 Lone Star Park at Grand Prairie Grand Prairie TX 11/5/2010 1/1/2011 65 12/8/2010 12/14/2010
252 Maverick Inc. Employee Health Care Benefits Plan North Salt Lake UT 10/26/2010 1/1/2011 794 12/6/2010 12/14/2010
253 Paloma Packing, Inc Santa Maris CA 11/10/2010 1/1/2011 49 12/14/2010 12/14/2010 254 Alaska Native Tribal Health Consortium Anchorage AK 11/30/2010 1/1/2011 488 12/15/2010 12/15/2010 255 Forest Products Inc. Group Health Plan Nashville TN 11/1/2010 1/1/2011 122 12/1/2010 12/15/2010 256 Joseph Gallo Farms Atwater CA 11/15/2010 1/1/2011 345 11/26/2010 12/15/2010
257 D'Arrigo Bros. Co. of California Salinas CA 11/12/2010 1/1/2011 2/1/2011 3,816 11/19/2010 12/17/2010
258 Paschall Truck Lines Inc. Murray KY 11/30/2010 1/1/2011 1/2/2011 54 12/13/2010 12/17/2010
259 Superior Services, Inc. Health and Welfare Plan Fresno CA 12/9/2010 1/1/2011 314 12/17/2010 12/17/2010
272 P-R Farms Inc. Clovis CA 11/22/2010 1/1/2011 128 12/15/2010 12/20/2010 273 American Eagle Outfitters Pittsburgh PA 11/16/2010 3/1/2011 9 11/23/2010 12/21/2010 274 Pak A Sak, Inc. Amarillo TX 11/22/2010 1/1/2011 40 12/21/2010 12/21/2010 275 PKC Investments, LLC West Monroe LA 12/15/2010 4/1/2011 215 12/22/2010 12/22/2010 276 Allied Pilots Association Fort Worth TX 12/7/2010 1/1/2011 678 12/13/2010 12/23/2010 277 Bartech Group Livonia MI 11/22/2010 4/1/2011 1,189 12/17/2010 12/23/2010 278 Dial Senior Management Inc* Omaha NE 11/30/2010 1/1/2011 127 12/21/2010 12/23/2010
294 Entrust Houston TX 11/30/2010 1/1/2011 2 12/21/2010 12/30/2010 295 GC Harvesting, Inc. Yuma AZ 12/20/2010 1/1/2011 2,500 12/23/2010 12/30/2010 296 Glen Curtis, Inc. #2143 Yuma AZ 12/3/2010 1/1/2011 227 12/21/2010 12/30/2010
297 Goodwill Industries of Central Indiana, Inc. Indianapolis IN 10/21/2010 1/1/2011 295 11/12/2010 12/30/2010
298 Hronis, Inc. Delano CA 11/9/2010 1/1/2011 928 12/30/2010 12/30/2010
299 Ingham County INGHAM COUNTY MI 12/22/2010 2/1/2011 42 12/27/2010 12/30/2010
300 Innovative Driver Services Company Charlotte NC 12/21/2010 2/1/2011 36 12/27/2010 12/30/2010 301 Jakov P. Dulcich & Sons McFarland CA 11/8/2010 1/1/2011 107 12/27/2010 12/30/2010 302 JLG Harvesting Inc. Yuma AZ 12/3/2010 1/1/2011 188 12/27/2010 12/30/2010 303 Johnson Machine Works, Inc. Chariton IA 11/24/2010 1/1/2011 191 12/16/2010 12/30/2010 304 Kent County* KENT COUNTY MI 12/22/2010 2/1/2011 10 12/27/2010 12/30/2010 305 MJ Soffe Fayetteville NC 12/21/2010 1/1/2011 270 12/28/2010 12/30/2010
306 Phoenix Children's Academy Scottsdale AZ 12/9/2010 12/16/2010 1/1/2011 985 12/16/2010 12/30/2010
307 San Bernardino IHSS Public Authority San Bernardino CA 12/1/2010 4/1/2011 1,317 12/22/2010 12/30/2010 308 SCC Healthcare Group, LLC Garland TX 12/27/2010 1/1/2011 105 12/28/2010 12/30/2010 309 Sitel Corporation Nashville TN 12/21/2010 7/1/2011 2,060 12/27/2010 12/30/2010 310 Sunview Vineyards of California, Inc. Delano CA 12/1/2010 1/1/2011 6,500 12/23/2010 12/30/2010
311 Tandem Eastern Inc. / Consolidated Transport Systems Inc.* St. Louis MI 11/23/2010 1/1/2011 601 12/28/2010 12/30/2010
312 Taylor Farms Texas, Inc. Dallas TX 11/29/2010 2/1/2011 121 12/22/2010 12/30/2010
313 The Public Authority of San Luis Obispo County San Luis Obispo CA 11/15/2010 2/1/2011 277 12/21/2010 12/30/2010
314 Tuff Shed, Inc. Denver CO 11/29/2010 4/1/2011 311 12/16/2010 12/30/2010 315 Westminster-Canterbury of Lynchburg Lynchburg VA 12/22/2010 1/1/2011 192 12/23/2010 12/30/2010
316 Fabri-Quilt North Kansas City MO 11/2/2010 1/1/2011 104 12/23/2010 1/3/2011
317 APTCO, Inc. Delano CA 12/1/2010 1/1/2011 121 12/16/2010 1/9/2011 318 Brevard Achievement Center, Inc. Rockledge FL 12/1/2010 6/1/2011 1,046 12/30/2010 1/12/2011
346 JK Guardian Security, Inc. Blue Island IL 12/1/2010 1/1/2011 89 12/29/2010 1/31/2011 347 Job Squad, Inc. Bridgeport WV 12/1/2010 1/1/2011 57 12/29/2010 1/31/2011 348 Lacks Stores, Inc. Victoria TX 12/9/2010 1/1/2011 962 1/11/2011 1/31/2011 349 Martin's Super Markets, Inc.* South Bend IN 12/16/2010 1/1/2011 662 1/14/2011 1/31/2011
350 Meridian Care Service San Antonio TX 12/16/2010 1/1/2011 190 1/19/2011 1/31/2011 2/2/2011
351 NANA Services, Inc Anchorage AK 12/1/2010 1/1/2011 161 12/29/2010 1/31/2011 352 NW Works, Inc Winchester VA 12/1/2010 1/1/2011 24 12/29/2010 1/31/2011 353 Pace Enterprises, Inc Morgantown WV 12/1/2010 1/1/2011 106 12/29/2010 1/31/2011 354 Pathways Welfare Benefit Plan Auburn ME 12/1/2010 1/1/2011 24 1/1/2011 1/31/2011 355 Portco, Inc. Portsmouth VA 12/1/2010 1/1/2011 51 12/29/2010 1/31/2011 356 Project Hired Portsmouth VA 12/1/2010 1/1/2011 59 12/29/2010 1/31/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
357 Sodexo Management Incorporated Welfare Benefit Plan Williamsville NY 12/1/2010 1/1/2011 586 12/29/2010 1/31/2011
358 Standardbred Owners Association Welfare Fund Yonkers NY 12/6/2010 1/1/2011 110 1/12/2011 1/31/2011
359 Transportation / Olympia Trails* Paramus NJ 12/1/2010 1/1/2011 207 12/29/2010 1/31/2011 360 TRDI San Antonio TX 12/1/2010 1/1/2011 128 12/29/2010 1/31/2011 361 Vocational Services Program Baltimore MD 12/1/2010 1/1/2011 31 12/29/2010 1/31/2011 362 VTC Enterprises Santa Maria CA 12/1/2010 1/1/2011 74 12/29/2010 1/31/2011 363 Weiser Security Services, Inc. New Orleans LA 12/1/2010 1/1/2011 124 12/29/2010 1/31/2011 364 Witco* Caldwell ID 12/1/2010 1/1/2011 20 12/29/2010 1/31/2011 365 Cardiovascular Home Care, Inc.* Fort Worth TX 12/30/2010 2/1/2011 3 1/25/2011 2/2/2011
366 Chicago Heights Steel Highway Steel Employee Health Care Plan Chicago Heights IL 12/30/2010 1/1/2011 331 1/14/2011 2/2/2011
367 CKE Restaurants, Inc. Carpinteria CA 12/10/2010 2/1/2011 20 1/14/2011 2/2/2011
368 Eddie Yaklin Employee Benefit Plan Trust Kingsville TX 1/20/2011 2/1/2011 16 1/24/2011 2/2/2011
369 Ford Storage & Moving Company Omaha NE 12/29/2010 2/1/2011 52 1/24/2011 2/2/2011 370 Jamba Juice Emeryville CA 12/17/2010 2/1/2011 125 1/19/2011 2/2/2011
371 South Texas Implement Company Alice TX 12/29/2010 2/1/2011 76 1/20/2011 2/2/2011 3/8/2011
372 Tom Raper, Inc. & Tom Raper Homes, Inc.* Richmond IN 1/20/2011
382 Anthony Vineyards Bakersfield CA 1/3/2011 2/1/2011 270 2/1/2011 2/14/2011 383 BET Production Services, Inc. Washington DC 12/22/2010 1/1/2011 135 1/25/2011 2/14/2011 384 Dental Care Alliance, LLC Sarasota FL 11/22/2010 1/1/2011 121 1/11/2011 2/14/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
385 Long Term Care Workers Health Trust Fund Los Angeles CA 11/22/2010 6/1/2011 4,700 1/12/2011 2/14/2011
386 Nayyarsons Deli Bakery Corporation Williston Park NY 1/24/2011 2/1/2011 387 1/28/2011 2/14/2011 387 Richard Bagdasarian, Inc. Mecca CA 1/3/2011 2/1/2011 815 1/31/2011 2/14/2011 388 RNRC Employee Benefit, Inc. Victoria TX 2/2/2011 2/1/2011 191 2/3/2011 2/14/2011 389 Saddlebrook Resorts, Inc. Wesley Chapel FL 12/30/2010 3/1/2011 80 1/25/2011 2/14/2011 390 Superior Copy* EL PASO TX 1/31/2011 1/1/2011 36 2/2/2011 2/14/2011 391 AAA Landscaping PHOENIX AZ 1/21/2011 4/1/2011 113 2/8/2011 2/15/2011 392 Adobe Equipment Houston, LLC Houston TX 1/24/2011 4/1/2011 267 1/24/2011 2/15/2011 393 Bee Sweet Citrus, Inc. Fowler CA 1/20/2011 3/1/2011 69 2/9/2011 2/15/2011 394 Breck Operating Corp. Breckenridge TX 1/26/2011 3/1/2011 40 2/4/2011 2/15/2011 395 Dobler & Sons, LLC. Moss Landing CA 1/12/2011 3/1/2011 335 1/12/2011 2/15/2011 396 EHC Management, L.L.C. Vancouver WA 1/15/2011 4/1/2011 568 2/2/2011 2/15/2011 397 Goodwill Industrial Services Corporation Colorado Springs CO 11/30/2010 1/1/2011 337 12/22/2010 2/15/2011 398 Hannon Security Services, Inc. St. Paul MN 12/28/2010 4/1/2011 64 2/4/2011 2/15/2011 399 Job Options, Inc. San Diego CA 1/24/2011 2/1/2011 461 1/28/2011 2/15/2011 400 John Moore Services, Inc.* Houston TX 1/26/2011 3/1/2011 142 2/9/2011 2/15/2011 401 Johnson Filtration Products, Inc. Amarillo TX 1/19/2011 3/1/2011 4 2/10/2011 2/15/2011 402 K&W Cafeterias, Inc. Winston-Salem NC 1/24/2011 2/1/2011 265 1/28/2011 2/15/2011 403 Loadcraft Industries, LTD Brady TX 12/15/2010 2/1/2011 229 1/28/2011 2/15/2011 404 RB Sandrini, Inc. Delano CA 1/4/2011 2/1/2011 63 2/2/2011 2/15/2011 405 The Hideaway, Inc. La Quinta CA 1/6/2011 1/1/2011 133 2/1/2011 2/15/2011 406 Topflavor Farms Inc.* Yuma AZ 12/8/2010 1/1/2011 189 2/1/2011 2/15/2011 407 West Coast Turf, Inc. Palm Desert CA 1/12/2011 3/1/2011 61 2/8/2011 2/15/2011
408 Western States Insulators and Allied Workers' Health Plan Alameda CA 11/29/2010 1/1/2011 3,936 2/10/2011 2/15/2011
409 ZV Pate/Scottish Foods Laurel Hill NC 1/21/2011 3/1/2011 94 1/21/2011 2/15/2011 410 Alabama Goodwill Industries Birmingham AL 1/24/2011 2/1/2011 59 1/28/2011 2/16/2011 411 Allied Cash Advance* Miami FL 1/26/2011 3/1/2011 157 2/14/2011 2/16/2011 412 CW Resources, Inc.* New Britain CT 1/24/2011 2/1/2011 89 1/28/2011 2/16/2011 413 Desert Fresh, Inc. Coachella CA 1/19/2011 3/1/2011 47 2/10/2011 2/16/2011 414 Golden Manufacturing Company, Inc. Golden MS 1/17/2011 3/1/2011 91 2/14/2011 2/16/2011
415 Goodwill Industries of North Georgia, Inc.* Atlanta GA 1/24/2011 3/1/2011 211 2/14/2011 2/16/2011
416 May Trucking Company Salem OR 1/20/2011 3/31/2011 340 1/28/2011 2/16/2011 417 Sportsman's Warehouse Health Plan Midvale UT 12/29/2010 1/1/2011 1,034 2/4/2011 2/16/2011 418 Sun Communities, Inc.* Southfield MI 12/20/2010 1/1/2011 262 1/24/2011 2/16/2011 419 Wateree Community Actions, Inc. Sumter SC 12/6/2010 2/1/2011 278 1/25/2011 2/16/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
420 Wisconsin Reinsurance Corporation Wellness Benefit Plan Madison WI 12/6/2010 1/1/2011 77 1/31/2011 2/16/2011
421 Military Deli & Bakery Services, Inc. Rancho Cucamonga CA 11/15/2010 1/1/2011 792 12/20/2010 2/17/2011
422 Classic Party Rentals Los Angeles CA 1/28/2011 5/1/2011 644 2/16/2011 2/22/2011 423 24-7 Long Term Care, Inc.* Bountiful UT 2/10/2011 3/1/2011 152 2/16/2011 2/24/2011 424 CHI Centers, Inc. Silver Springs MD 1/26/2011 3/1/2011 31 2/15/2011 2/24/2011 425 Cohn Turner Associates, Inc. Baton Rouge LA 1/6/2011 2/1/2011 8 2/15/2011 2/24/2011 426 Crescent Guardian* New Orleans LA 1/26/2011 3/1/2011 126 2/15/2011 2/24/2011 427 Elite Investigations New York NY 11/2/2010 5/1/2011 253 12/13/2010 2/24/2011 428 Golden Valley Grape Juice & Wine, LLC Madera CA 2/2/2011 3/1/2011 41 2/18/2011 2/24/2011 429 M&N Contractors Silver Springs MD 1/26/2011 3/1/2011 44 2/15/2011 2/24/2011 430 Metropolitan Building Services Washington DC 1/26/2011 3/1/2011 12 2/15/2011 2/24/2011 431 MVLE Springfield VA 1/26/2011 3/1/2011 108 2/15/2011 2/24/2011
432 R & R Janitorial, Painting & Building Services, Inc. Washington DC 1/26/2011 3/1/2011 119 2/15/2011 2/24/2011
433 Snelling Staffing Services Dallas TX 1/31/2011 2/21/2011 20 2/16/2011 2/24/2011 434 The Jewel Date Company, Inc. Palm Desert CA 1/31/2011 3/1/2011 73 1/31/2011 2/24/2011 435 Wallace Associates, Ltd Maitland FL 1/6/2011 2/1/2011 23 2/15/2011 2/24/2011 436 Wharton-Smith, Inc. Sanford FL 1/28/2011 4/1/2011 102 2/16/2011 2/24/2011 437 Capco, Inc. Grand Junction CO 1/20/2011 1/1/2011 262 1/31/2011 2/25/2011 438 Jasmine Vineyards, Inc. Delano CA 1/31/2011 2/1/2011 1,367 1/31/2011 2/25/2011 439 American Kiosk Management LLC* Las Vegas NV 1/19/2011 1/1/2011 128 2/22/2011 3/1/2011 440 Construction Protective Services, Inc Gardena CA 2/14/2011 3/1/2011 145 2/14/2011 3/1/2011 441 Labcon, Inc. Grand Prairie TX 2/9/2011 6/1/2011 192 2/18/2011 3/1/2011 442 Monterey Mushrooms, Inc. Watsonville CA 2/4/2011 7/1/2011 2,428 2/24/2011 3/1/2011 443 O.M. Contracting, Inc. Thermal CA 1/14/2011 3/1/2011 26 2/22/2011 3/1/2011
444 Wildwood Programs Prescription Drug Benefit Schenectady NY 2/14/2011 7/1/2011 756 2/14/2011 3/1/2011
445 Manning Building Supplies, Inc. Jacksonville FL 2/24/2011 9/1/2011 211 2/28/2011 3/2/2011 446 Pac West Solutions, Inc. Pleasanton CA 2/3/2011 3/1/2011 46 2/23/2011 3/2/2011 447 Riesbeck Food Markets, Inc. St. Clairsville OH 2/11/2011 4/1/2011 1,406 2/22/2011 3/2/2011
448 Southern Motion, Inc. Employee Welfare Benefit Plan Pontotoc MS 1/25/2011 4/1/2011 1,357 2/22/2011 3/2/2011
449 W.N. Morehouse Truck Line, Inc. Omaha NE 2/22/2011 4/1/2011 138 2/28/2011 3/2/2011 450 Cost Plus, Inc. Oakland CA 1/14/2011 3/1/2011 23 2/24/2011 3/7/2011 451 Goodwill Industries of San Antonio San Antonio TX 11/30/2010 1/1/2011 474 3/1/2011 3/7/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
452 Silverado Senior Living Holdings, Inc. Irvine CA 2/15/2011 7/1/2011 341 2/28/2011 3/7/2011 453 Cal Pacific Farm Management LP Richgrove CA 9/29/2010 1/1/2011 673 2/28/2011 3/8/2011 454 International Coffee & Tea Los Angeles CA 2/3/2011 4/1/2011 121 3/7/2011 3/8/2011 455 Lexus of Austin* Austin TX 2/24/2011 5/1/2011 98 3/7/2011 3/8/2011
456 Tumex Corporation dba Specialty Electric Yuma AZ 2/23/2011 3/1/2011 31 3/7/2011 3/8/2011
457 BRP Health Management Systems, Inc. Pocatello ID 1/28/2011 3/1/2011 103 2/28/2011 3/10/2011 458 Emeritus Senior Living, Inc. Seattle WA 2/22/2011 8/1/2011 9,855 3/1/2011 3/10/2011 459 DMS Roofing Yuma AZ 2/23/2011 3/1/2011 18 3/7/2011 3/14/2011
460 American Hospitality Management Company Houston TX 2/28/2011 4/1/2011 111 3/11/2011 3/17/2011
461 Belo Tank Xpress, LLC Conroe TX 2/25/2011 4/1/2011 29 3/14/2011 3/17/2011 462 Don Davis Auto Group Arlington TX 2/28/2011 4/1/2011 150 3/11/2011 3/17/2011
471 Goodwill Industries of Lower South Carolina, Inc. North Charleston SC 11/30/2010 1/1/2011 442 3/7/2011 3/21/2011
472 Arby's Restaurant Group, Inc. Atlanta GA 3/2/2011 4/1/2011 19 3/2/2011 3/30/2011 473 Aspen Foods, a division of Koch Foods Chicago IL 2/25/2011 5/1/2011 232 3/21/2011 3/30/2011 474 Automatic Products Corporation Garland TX 1/4/2011 9/1/2011 82 3/17/2011 3/30/2011 475 Beacon Group SW, Inc. Tucson AZ 3/7/2011 7/1/2011 17 3/23/2011 3/31/2011 476 Blue Lake Rancheria Blue Lake CA 2/28/2011 1/1/2011 333 3/17/2011 3/31/2011 477 Clean Tech/WFF Facility Services St. Louis MO 3/1/2011 5/1/2011 79 3/18/2011 3/31/2011 478 D&M Carriers, Inc. Oklahoma City OK 12/8/2010 9/1/2011 323 3/21/2011 3/31/2011
479 Imperial County Work Training Center, Inc. El Centro CA 3/7/2011 7/1/2011 25 3/23/2011 3/31/2011
480 Licking Knox Goodwill Industries, Inc. Newark OH 3/16/2011 7/1/2011 206 3/25/2011 3/31/2011 481 Marek Brothers Companies Houston TX 3/7/2011 7/1/2011 915 3/24/2011 3/31/2011 482 Public Employees' Local Union 1033 Providence RI 12/14/2010 7/1/2011 883 3/17/2011 3/31/2011 483 Senior Care Centers Management, Inc. Dallas TX 3/4/2011 5/1/2011 159 3/22/2011 3/31/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
484 Earthbound Farm San Juan Bautista CA 3/2/2011 8/1/2011 923 3/2/2011 4/4/2011
485 L&H Packing Company San Antonio TX 1/19/2011 5/1/2011 279 3/18/2011 4/4/2011 486 Carruth Doggett* Houston TX 3/9/2011 7/1/2011 110 4/1/2011 4/6/2011 487 JMW Truss & Components Cathedral City CA 3/22/2011 4/1/2011 63 3/22/2011 4/6/2011
488 Physical Distribution Services, Inc. (PDSI) Minneapolis MN 3/17/2011 8/1/2011 3,018 4/1/2011 4/6/2011
489 Quick Refrigeration Co. Yuma AZ 3/22/2011 5/1/2011 11 3/22/2011 4/6/2011 490 Royal Medjool Date Farms Yuma AZ 3/14/2011 5/1/2011 14 3/28/2011 4/6/2011 491 Styrotek, Inc. Delano CA 3/14/2011 4/1/2011 25 3/14/2011 4/6/2011 492 Trueline Trucking Las Vegas NV 3/14/2011 6/1/2011 966 3/14/2011 4/6/2011 493 Wendy's International, Inc. Atlanta GA 3/2/2011 4/1/2011 22 3/2/2011 4/6/2011 494 Public Employees Local 71 Trust Fund Anchorage AK 3/16/2011 7/1/2011 413 4/4/2011 4/7/2011 495 ANCIRA ENTERPRISES, INC. SAN ANTONIO TX 3/7/2011 6/1/2011 70 3/29/2011 4/11/2011 496 Autumn Health Care, LLC Newark OH 3/23/2011 5/1/2011 186 4/5/2011 4/11/2011 497 Choctaw Nation of Oklahoma Durant OK 1/4/2011 2/1/2011 613 3/28/2011 4/11/2011 498 Corestaff Services Houston TX 3/14/2011 4/18/2011 70 3/14/2011 4/11/2011 499 Dillard's, Inc. Little Rock AR 3/11/2011 6/1/2011 1,676 3/29/2011 4/11/2011
500 Life Options, Vocational & Resource Center, Inc. Lompoc CA 3/18/2011 6/1/2011 17 4/1/2011 4/11/2011
501 Mascorro Concrete Construction, Inc. Thousand Palms CA 3/23/2011 6/1/2011 30 4/6/2011 4/11/2011 502 Maxim Healthcare Services, Inc. Columbia MD 3/14/2011 6/1/2011 1,395 4/4/2011 4/11/2011 503 McCormick and Schmicks Portland OR 3/14/2011 5/1/2011 966 3/28/2011 4/11/2011 504 Pipe Distributors Ltd Houston TX 3/21/2011 4/1/2011 43 4/5/2011 4/11/2011 505 Prasek's Hillje Smokehouse El Campo TX 3/21/2011 5/1/2011 49 4/4/2011 4/11/2011 506 Turnpike Ford, Inc. Charlston WV 3/11/2011 5/1/2011 71 3/28/2011 4/11/2011 507 W.E. Blain & Sons, Inc. Mt. Olive MS 3/14/2011 5/1/2011 101 3/14/2011 4/11/2011 508 Challenge Unlimited, Inc. Alton IL 2/28/2011 4/1/2011 281 2/28/2011 4/19/2011 509 Dorado Services, Inc. Sanford FL 2/28/2011 4/1/2011 51 2/28/2011 4/19/2011 510 Giumarra Vineyards Corporation Edison CA 3/3/2011 4/1/2011 1,693 3/3/2011 4/19/2011
511 Goodwill Easter Seals of the Gulf Coast, Inc. Mobile AL 2/28/2011 4/1/2011 38 2/28/2011 4/19/2011
512 Ho-Chunk Nation Black River Falls WI 3/18/2011 7/1/2011 304 4/13/2011 4/19/2011
513 Opportunity Center - Easter Seal Welfare Benefits Aninston AL 2/28/2011 4/1/2011 54 2/28/2011 4/19/2011
514 Relief Enterprise, Inc. Welfare Benefit Plan Austin TX 2/28/2011 4/1/2011 262 2/28/2011 4/19/2011
515 W A & M Health Care Providers Lancaster OH 3/16/2011 4/15/2011 88 4/7/2011 4/19/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
516 Agape Senior* West Columbia SC 3/14/2011 9/23/2010 60 4/13/2011 4/20/2011 517 B&E Industries* Arlington TX 3/31/2011 4/1/2011 70 4/15/2011 4/20/2011 518 Gold Metal Recyclers, Ltd. Dallas TX 2/28/2011 4/1/2011 107 4/18/2011 4/20/2011 519 Solano County IHSS Public Authority Fairfield CA 3/24/2011 7/1/2011 575 4/11/2011 4/22/2011 520 ABM Janitorial Services Houston TX 3/31/2011 5/1/2011 62 4/20/2011 4/25/2011 521 Chesapeake Service Systems* Chesapeake VA 3/31/2011 5/1/2011 83 4/20/2011 4/25/2011 522 Chuchian Ranch, Inc. Coachella CA 3/18/2011 4/1/2011 45 3/30/2011 4/25/2011
523 Crown Hill Ranches, Inc. Coachella CA 3/31/2011 4/7/2011 6/1/2011 117
4/20/2011 4/28/2011
4/25/2011 5/5/2011
524 Didlake Inc. Manassas VA 3/31/2011 5/1/2011 104 4/21/2011 4/25/2011 525 Eckert Cold Storage Co. Escalon CA 4/1/2011 6/1/2011 5 4/1/2011 4/25/2011 526 Gibson & Schaefer, Inc. Heber CA 3/18/2011 3/1/2011 99 3/30/2011 4/25/2011 527 Grimmway Enterprises, Inc. Arvin CA 3/28/2011 6/1/2011 6,306 3/28/2011 4/25/2011 528 Kerley Homes of Yuma, LLC Yuma AZ 4/5/2011 6/1/2011 6 4/5/2011 4/25/2011 529 Pack-Ryt La Quinta CA 3/18/2011 5/1/2011 40 3/30/2011 4/25/2011 530 REI Washington WA 3/18/2011 5/1/2011 1,180 3/30/2011 4/25/2011
569 Mays Housecall Home Health Inc. Antlers OK 4/18/2011 7/1/2011 127 5/6/2011 6/7/2011
570 Pecan Valley Rehabilitation & Healthcare Center San Antonio TX 4/26/2011 6/1/2011 39 5/11/2011 6/7/2011
571 Southwest LTC Frisco TX 4/26/2011 7/1/2011 220 5/11/2011 6/7/2011 572 Air Central Heating & Cooling Yuma AZ 5/3/2011 5/1/2011 7 5/3/2011 6/8/2011 573 Spanish Meadows Brownsville TX 5/9/2011 8/1/2011 195 6/1/2011 6/8/2011 574 Wesco Industrial Products Co. Lansdale PA 5/9/2011 5/1/2011 94 6/2/2011 6/8/2011 575 Cameron Mitchell Restaurant* Columbus OH 5/13/2011 8/1/2011 110 6/3/2011 6/9/2011 576 Hadley, Inc. Thermal CA 5/13/2011 7/1/2011 18 6/3/2011 6/9/2011 577 Atrium Centers, LLC Cincinnati OH 4/4/2011 9/1/2011 1,060 5/18/2011 6/13/2011 578 Kovacevich 5 Farms Delano CA 6/2/2011 6/1/2011 411 6/2/2011 6/13/2011 579 Fresh Harvest, Inc. Somerton AZ 5/16/2011 7/1/2011 55 6/7/2011 6/14/2011 580 Pasquinelli Produce Co Yuma AZ 5/16/2011 7/1/2011 518 6/8/2011 6/14/2011 581 U. S. Security Associates, Inc. Roswell GA 5/17/2011 9/1/2011 721 6/8/2011 6/14/2011
Total Enrollment 458,529
Section B: Section B lists plans that did not apply for a one year waiver under the initial policy but did apply for, and received, a waiver good through 2013, under the June 17, 2011 policy. Plans must submit annual information about their plan and comply with requirements to ensure that their enrollees understand the limits of their coverage.
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
1 Evans Properties, Inc. Vero Beach FL 5/12/2011 8/1/2011 55 6/15/2011 6/20/2011 2 Fisher Ranch, LLC Blythe CA 5/12/2011 7/1/2011 188 5/12/2011 6/20/2011 3 Triad Transport, Inc. McAlester OK 5/10/2011 6/1/2011 12 6/13/2011 6/20/2011
4
Fleetwood Carriers, Inc. (dba Fleetwood Transportation Services, Inc. & Fleetwood Logistics, Inc.) Diboll TX 5/25/2011 7/1/2011 95 5/25/2011 6/21/2011
5 Mount Vernon Mills Inc. Greenville SC 3/29/2011 5/1/2011 128 5/3/2011 6/21/2011 6 World Car Auto Group San Antonio TX 4/25/2011 7/1/2011 269 6/2/2011 6/21/2011
8 Bidart Bros. Bakersfield CA 3/22/2011 6/1/2011 201 5/20/2011 6/22/2011 9 Landscape Development, Inc. Valencia CA 5/13/2011 7/1/2011 205 5/13/2011 6/22/2011
10 Citrus Care, Inc. Somerton AZ 5/31/2011 6/1/2011 7 6/15/2011 6/27/2011 11 Forged Components, Inc. Humble TX 5/26/2011 7/1/2011 59 5/26/2011 6/27/2011
12 Hamilton Printing Company Castleton on the Hudson NY 5/20/2011 7/1/2011 156 6/20/2011 6/27/2011
13 J.L Padilla & Sons Labor Service, Inc. Coachella CA 5/31/2011 7/1/2011 121 6/21/2011 6/27/2011 14 Midwest Health Topeka KS 5/20/2011 7/1/2011 285 6/16/2011 6/27/2011
15 Piping Technology & Products, Inc. Employee Benefit Plan Houston TX 5/20/2011 9/1/2012 340 5/20/2011 6/27/2011
16 The Bailey Company Golden CO 5/31/2011 7/1/2011 222 6/21/2011 6/27/2011 17 Bill Miller Bar-B-Q Enterprises, Ltd. San Antonio TX 5/10/2011 8/1/2011 1,083 5/10/2011 6/28/2011 18 CAG Dairy Management Cimmaron KS 5/17/2011 9/1/2011 54 6/9/2011 6/28/2011 19 Central Arkansas Nursing Centers, Inc. Ft. Smith AR 5/19/2011 8/1/2011 1,379 6/13/2011 6/28/2011 20 Central States Trucking Co. Bensenville IL 5/20/2011 8/1/2011 260 6/9/2011 6/28/2011 21 Cranesville Block Company, Inc. Amsterdam NY 5/23/2011 8/1/2011 134 6/21/2011 6/28/2011 22 Dungarvin Group Inc. St. Paul MN 5/10/2011 9/1/2011 118 5/10/2011 6/28/2011 23 Employers Resource Boise ID 3/14/2011 1/1/2011 186 6/15/2011 6/28/2011 24 Gulf Compress, Inc. Corpus Christi TX 5/31/2011 7/1/2011 0 6/15/2011 6/28/2011
25 National Council for Air and Stream Improvement, Inc Durham NC 5/24/2011 7/1/2011 8 6/13/2011 6/28/2011
26 Rite Style Optical Omaha NE 5/31/2011 7/1/2011 75 6/21/2011 6/28/2011 27 Tip Top Poultry Marietta GA 5/23/2011 7/1/2011 39 6/20/2011 6/28/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
28 Hodge Company, Inc. Dubuque IA 5/25/2011 6/1/2011 407 5/25/2011 6/29/2011 29 Sarah Farms Yuma AZ 6/16/2011 7/1/2011 373 6/16/2011 6/29/2011 30 IBS Industries Independence MO 5/31/2011 7/1/2011 61 5/31/2011 6/30/2011 31 On Our Own Services Houston TX 5/31/2011 7/1/2011 77 5/31/2011 6/30/2011 32 Securiguard McLean VA 5/31/2011 7/1/2011 123 5/31/2011 6/30/2011 33 Sunshine Mills, Inc Red Bay AL. 5/6/2011 5/1/2011 85 6/15/2011 6/30/2011 34 The Container Store Coppell TX 6/17/2011 7/1/2011 432 6/29/2011 7/1/2011
35 ASP Farm Services Delano CA 6/9/2011 9/6/2011 7/1/2011 77
6/28/2011 9/6/2011
7/5/2011 9/15/2011
36 Azcona Harvesting, LLC Greenfield CA 6/7/2011 7/1/2011 109 6/26/2011 7/5/2011 37 CCS VEBA Evanston IL 6/13/2011 8/1/2011 216 6/29/2011 7/5/2011 38 Central Health Corporation Rogers AR 6/6/2011 8/1/2011 230 6/29/2011 7/5/2011 39 Famco A/C & Refrigeration, Inc. San Luis AZ 6/8/2011 7/1/2011 13 6/26/2011 7/5/2011 40 Sun Pacific Farming, Inc. Bakersfield CA 6/14/2011 8/1/2011 897 6/26/2011 7/5/2011 41 Vignolo Farms Shafter CA 6/8/2011 7/1/2011 106 6/26/2011 7/5/2011 42 Wilson Oil, Inc Longview WA 6/6/2011 8/1/2011 49 6/29/2011 7/5/2011 43 Summer Kitchen Café Omaha NE 5/31/2011 7/1/2011 46 7/1/2011 7/6/2011 44 Englefield, Inc. Heath OH 6/7/2011 1/1/2011 227 6/29/2011 7/7/2011 45 Land Coast Insulation, Inc. New Iberia LA 6/13/2011 8/1/2011 121 7/5/2011 7/7/2011 46 TakeCare Insurance Company, Inc Tamuning GU 6/15/2011 1/1/2011 523 7/7/2011 7/11/2011 47 LS Farms, Inc. McFarland CA 6/2/2011 8/1/2011 261 7/5/2011 7/12/2011 48 Newark Extended Care Center Newark NJ 6/20/2011 8/1/2011 398 7/7/2011 7/12/2011 49 Desert Valley Date Coachella CA 6/15/2011 8/1/2011 37 6/15/2011 7/13/2011 50 Sun Pacific Harvesting, Inc. Exeter CA 6/16/2011 8/1/2011 759 6/17/2011 7/13/2011
51 International Bank of Commerce of Laredo Laredo TX 4/29/2011 6/1/2011 1,918 6/30/2011 7/14/2011
52 International Bank of Commerce of Oklahoma Laredo TX 4/29/2011 6/1/2011 348 6/30/2011 7/14/2011
53 Lettuce Entertain You Enterprises Chicago IL 6/17/2011 9/1/2011 1,655 7/12/2011 7/15/2011 54 A Plus Benefits, Inc. Lindon UT 6/1/2011 6/1/2011 12,310 7/6/2011 7/21/2011
55 New York Public Library Astor, Lenox, & Tilden Foundation New York NY 11/30/2010 1/1/2011 111 3/17/2011 7/21/2011
56 Zavala County Crystal City TX 5/11/2011 6/1/2011 55 7/13/2011 7/21/2011 57 General Insulation, Inc Theodore AL 6/2/2011 9/1/2011 185 7/15/2011 7/25/2011 58 Shoe Sensation, Inc. Jeffersonville IN 7/7/2011 9/1/2011 128 7/7/2011 7/25/2011
59 Wyoming Lodging and Restaurant Association Cheyenne WY 6/2/2011 7/1/2011 170 7/15/2011 7/25/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
60 Christianson Air Conditioning and Plumbing Round Rock TX 6/30/2011 9/1/2011 77 6/30/2011 7/26/2011
61 Health Systems, Inc. Osage Beach MO 5/25/2011 7/1/2011 1,524 5/25/2011 7/26/2011 62 Restaurant Management Group Concord NC 5/31/2011 7/1/2011 99 7/1/2011 7/26/2011 63 Pensacola Christian College Pensacola FL 4/28/2011 9/1/2011 1,196 6/15/2011 7/27/2011 64 Tower Packaging Stores, Inc. Doraville GA 7/12/2011 8/1/2011 103 7/26/2011 7/28/2011 65 Dubois Machine Company Columbus IN 4/19/2011 5/1/2011 60 7/26/2011 7/29/2011 66 Haberfelde Ford dba Jim Burke Ford Bakersfield CA 5/31/2011 7/1/2011 52 7/22/2011 7/29/2011 67 Northwood Investments Corp. La Grande OR 7/11/2011 9/1/2011 419 7/26/2011 7/29/2011
68 Hill Country Community Mental Health and Mental Retardation Center Lubbock TX 7/26/2011 9/1/2011 55 7/26/2011 8/9/2011
69 L & R Corporation Somerton AZ 7/22/2011 8/1/2011 26 7/22/2011 8/9/2011 70 O'Hair Shutters, Ltd Lubbock TX 7/26/2011 9/1/2011 89 7/26/2011 8/9/2011 71 Accent Career Services, Inc. Houston TX 6/29/2011 8/1/2011 60 7/28/2011 8/10/2011 72 Betteravia Farms, LLC Santa Maria CA 6/16/2011 8/1/2011 269 8/2/2011 8/10/2011 73 Oceano Farming Co. LLC Santa Maria CA 6/16/2011 8/1/2011 9 8/2/2011 8/10/2011 74 Panera, LLC St. Louis MO 6/30/2011 1/1/2011 2,782 6/30/2011 8/10/2011 75 Royal Oak Enterprises, LLC Roswell GA 6/16/2011 9/1/2011 83 7/27/2011 8/10/2011 76 SCOTT PETROLEUM Itta Bena MS 7/5/2011 8/1/2011 334 7/7/2011 8/10/2011 77 Wycliffe Bible Translators Orlando FL 7/25/2011 10/1/2011 4,748 7/25/2011 8/10/2011
78
America's Pizza Company, LLC Employee Benefit Plan (Indemnity Medical Plan) Lafayette LA 8/4/2011 9/1/2011 396 8/4/2011 8/11/2011
79 Bigelow Management, Inc Las Vegas NV 8/3/2011 9/1/2011 306 8/3/2011 8/11/2011 80 Ed Nance Drywall, Inc. Fresno CA 8/2/2011 9/1/2011 14 8/2/2011 8/11/2011 81 Griffith Bros Orange CA 8/1/2011 9/1/2011 35 8/9/2011 8/11/2011 82 ReadyOne Industries, Inc. El Paso TX 8/3/2011 8/1/2011 566 8/3/2011 8/11/2011 83 Stake Center Locating Salt Lake UT 8/3/2011 1/1/2011 115 8/3/2011 8/11/2011 84 Terrible Herbst Oil Company Las Vegas NV 7/29/2011 6/1/2011 820 8/9/2011 8/11/2011 85 Limoneira Company Santa Paula CA 8/1/2011 9/1/2011 61 8/1/2011 8/12/2011 86 Auto Systems Centers, Inc. Toledo OH 8/1/2011 9/1/2011 704 8/11/2011 8/17/2011 87 Langston Companies Inc. Memphis TN 8/1/2011 7/1/2011 232 8/1/2011 8/17/2011
88 Universal Industrial Sales, Inc. - UIS Basic Med Lindon UT 7/21/2011 8/1/2011 58 8/12/2011 8/17/2011
89 Goodall-Witcher Healthcare Foundation Clifton TX 7/29/2011 9/1/2011 328 8/15/2011 8/19/2011 90 Avalon Staffing, LLC Oklahoma City OK 7/29/2011 9/1/2011 233 7/29/2011 8/25/2011 91 BLDM, LLC San Juan PR 7/29/2011 9/1/2011 1,784 7/29/2011 8/25/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
92 F.I.R.M, Inc Yuma AZ 8/17/2011 9/1/2011 26 8/17/2011 8/25/2011
93 Local 125 IATSE Health and Welfare Fund Marion IN 7/29/2011 9/1/2012 19 7/29/2011 8/25/2011
94 Rosenberg Auto Investors, LP DBA Legacy Ford Lincoln Mercury Rosenberg TX 7/19/2011 9/1/2011 105 8/4/2011 8/25/2011
95 School Cafeteria Employees Unite/Here Local NO 634 Health & Welfare Fund Valley Forge PA 7/28/2011 9/1/2011 3,374 7/28/2011 8/25/2011
96 The Dimare Company Fresno CA 7/28/2011 8/1/2011 43 7/28/2011 8/25/2011 97 Watkins and Shepard Trucking, Inc. Montana MT 7/29/2011 10/1/2011 21 7/29/2011 8/25/2011 98 Land View Rupert ID 12/21/2010 1/1/2011 37 7/29/2011 8/31/2011 99 Skyview Cooling Company Yuma AZ 8/23/2011 1/1/2011 93 8/23/2011 8/31/2011 100 Smitty's Body Shop Yuma AZ 7/27/2011 8/1/2011 10 7/27/2011 8/31/2011 101 Washington State Migrant Council Sunnyside WA 8/25/2011 11/1/2010 30 8/25/2011 8/31/2011 102 Westco of Oklahoma, Inc. Miami OK 8/22/2011 9/1/2011 66 8/22/2011 8/31/2011 103 Mission Aviation Fellowship Nampa ID 8/25/2011 1/1/2012 282 8/25/2011 9/1/2011 104 New Tribes Mission Sanford FL 8/25/2011 1/1/2012 906 8/25/2011 9/1/2011 105 Yamaha Corporation of America Buena Park CA 8/25/2011 1/1/2012 408 8/25/2011 9/1/2011 106 Regency Healthcare and Rehab Niles IL 7/20/2011 9/1/2011 104 8/5/2011 9/13/2011 107 HCJB Global Colorado Springs CO 9/1/2011 1/1/2012 20 9/1/2011 9/14/2011 108 RCO Limited Columbus OH 9/1/2011 1/1/2012 194 9/2/2011 9/15/2011 109 Red Cloud Indian School Pine Ridge SD 8/30/2011 7/1/2011 54 9/16/2011 9/21/2011 110 Sargento Foods Inc. Plymouth WI 8/31/2011 1/1/2012 2,551 9/7/2011 9/23/2011 111 The Evangelical Alliance Mission Carol Stream IL 9/1/2011 1/1/2012 864 9/12/2011 9/23/2011 112 Comite de Bien Estar, Inc. Fresno CA 9/9/2011 9/1/2011 20 9/26/2011 9/27/2011 113 Icon Information Collection Houston TX 9/21/2011 11/1/2011 29 9/25/2011 9/27/2011 114 Western Range Association Salt Lake City UT 9/12/2011 1/1/2011 900 9/26/2011 9/27/2011
115 Gilster-Mary Lee Corporation Group Health Benefit Plan Chester IL 9/16/2011 1/1/2012 5,290 9/27/2011 9/28/2011
116 Pioneers Orlando FL 9/15/2011 5/1/2012 1,676 9/27/2011 9/28/2011 117 The Navigators Colorado Springs CO 9/13/2011 1/1/2012 1,103 9/13/2011 9/28/2011 118 Specialty's Café & Bakery San Francisco CA 2/18/2011 11/1/2010 64 9/23/2011 10/3/2011 119 DRS Returns Reading PA 9/22/2011 1/1/2011 46 9/22/2011 10/11/2011 120 Crossroads Diversified Services, Inc. Sacramento CA 9/22/2011 3/1/2011 65 10/11/2011 10/17/2011 121 Elywn, Inc. Aston PA 9/22/2011 8/1/2011 138 10/11/2011 10/17/2011
122 Santa Monica Police Officers' Assn Benefits Trust City of Industry CA 9/21/2011 1/1/2011 386 10/17/2011 10/17/2011
123 Whittlesea Bell Reno NV 9/21/2011 10/1/2010 26 9/21/2011 10/17/2011
Applicant City** State Application
Date
Plan Effective
Date
Number of
Enrollees Application Completed
Waiver Date
124 Bally Total Fitness Holding Corporation Chicago IL 9/21/2011 4/1/2011 29 9/26/2011 10/18/2011 125 Great Plains Enterprises, Inc. Las Vegas NV 9/22/2011 9/1/2011 155 10/13/2011 10/18/2011 126 Modern Facilities Services, Inc. East Hanover NJ 9/22/2011 8/1/2011 35 10/11/2011 10/18/2011 127 Services Disabled Veterans Business Silver Spring MD 9/22/2011 8/1/2011 55 10/11/2011 10/18/2011 128 Gulf Coast Enterprises Pensacola FL 9/22/2011 9/1/2011 867 10/13/2011 10/19/2011 129 SW Resources, Inc. Parkersburg WV 9/22/2011 9/1/2011 51 10/13/2011 10/19/2011
130 Transitions MHR (Alliance of the Mentally Ill) Rock Island IL 9/22/2011 8/1/2011 23 10/12/2011 10/19/2011
131 Palm Springs General Hospital, Inc Hialeah FL 6/30/2011 8/1/2011 621 6/30/2011 10/27/2011 132 ReadyOne Industries El Paso TX 6/21/2011 8/1/2011 566 6/21/2011 10/27/2011 133 VGS, Inc. Cleveland OH 9/22/2011 8/1/2011 41 10/25/2011 10/31/2011 134 Alliance, Inc. Baltimore MD 9/22/2011 9/1/2011 121 10/12/2011 11/2/2011 135 Landmark Services, Inc. Santa Ana CA 9/22/2011 8/1/2011 104 10/12/2011 11/2/2011 136 The Arc of San Diego San Diego CA 9/22/2011 9/1/2011 426 10/12/2011 11/2/2011 137 Citizen Advocates, Inc. Malone NY 5/31/2011 1/1/2011 871 10/26/2011 11/14/2011 138 TexHealth Harris County 3-Share Plan Houston TX 9/16/2011 1/1/2011 250 11/10/2011 12/1/2011 139 Ambassador Thomasville GA 9/22/2011 9/23/2010 177 11/16/2011 12/7/2011 140 UTMB Health Multi-Share Plan Galveston TX 9/14/2011 9/23/2010 457 12/13/2011 12/13/2011 141 BarDett, LLC Memphis TN 9/20/2011 9/1/2011 115 12/14/2011 12/14/2011
Total Enrollment 69,813
*Waiver not extended; expires one year after plan effective date.
**Please note that the city and state correspond only to the address stated on the application and may not reflect the location of the applicant’s enrollees.
