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<div class="WordSection1">
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Good Morning,<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">We are asking you to please take a few minutes and respond to this email, answering the questions below about the Bronze Plan option. We only need one
response per entity. Thank you in advance for your help.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">You will fall into one of the following categories. We only need you to answer the questions in the appropriate category:
<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.0in;text-indent:-1.0in"><b><u><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">CATEGORY 1</span></u></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">:
Your entity <b>elected to offer </b>the Bronze Plan option to your employees for the 2015-16 Plan Year who are not benefit eligible and not receiving an employer contribution, but meet the requirements under the ACA:<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in;text-indent:-.25in;mso-list:l1 level1 lfo1">
<![if !supportLists]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><span style="mso-list:Ignore">A)<span style="font:7.0pt "Times New Roman"">
</span></span></span><![endif]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Will your entity be able to avoid all of the penalties by meeting the affordability requirements?
<o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">(mark with “X”)
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">__</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Yes</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">__</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">No</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left:.5in"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in;text-indent:-.25in;mso-list:l1 level1 lfo1">
<![if !supportLists]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><span style="mso-list:Ignore">B)<span style="font:7.0pt "Times New Roman"">
</span></span></span><![endif]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">If you answered “Yes,” how are you ensuring these requirements are met in offering the Bronze Plan option?<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.0in;text-indent:-1.0in"><b><u><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">CATEGORY 2</span></u></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">:<span style="color:#44546A">
</span>Your entity <b>did not elect to offer</b> the Bronze Plan option to employees for the 2015-16 Plan Year who are not benefit eligible, but meet the ACA requirement to offer benefits:<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in;text-indent:-.25in;mso-list:l0 level1 lfo2">
<![if !supportLists]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><span style="mso-list:Ignore">A)<span style="font:7.0pt "Times New Roman"">
</span></span></span><![endif]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Did you make these employees benefit eligible? (mark with “X”)<span style="color:#44546A">
</span></span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">___</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Yes</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">___</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">No</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left:.5in"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in;text-indent:-.25in;mso-list:l0 level1 lfo2">
<![if !supportLists]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><span style="mso-list:Ignore">B)<span style="font:7.0pt "Times New Roman"">
</span></span></span><![endif]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Did you offer another plan option to these individuals? (mark with “X”)
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">___</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Yes</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">___</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">No</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p></o:p></span></p>
<p class="MsoNormal" style="margin-left:.5in"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:.75in;text-indent:.5in"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">If
<b>Yes</b>, which Plan(s)?<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in;text-indent:-.25in;mso-list:l0 level1 lfo2">
<![if !supportLists]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><span style="mso-list:Ignore">C)<span style="font:7.0pt "Times New Roman"">
</span></span></span><![endif]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Did you provide an employer contribution to these employees? (mark with “X”)
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">___</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Yes</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">
</span><span style="font-size:14.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">___</span><b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">No</span></b><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.0in;text-indent:.25in"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">If
<b>Yes</b>, how much? __________________________________________<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal" style="margin-left:1.25in;text-indent:-.25in;mso-list:l0 level1 lfo2">
<![if !supportLists]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><span style="mso-list:Ignore">D)<span style="font:7.0pt "Times New Roman"">
</span></span></span><![endif]><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">How do you evaluate to ensure the plan offerings meet the ACA affordability requirement?<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Name of person completing questionnaire: _______________________________________
<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Title: _______________________<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif;mso-fareast-language:JA">Name of entity: ____________________________________<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif">Please send your response to:<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:Forte">DeeDee Voigt<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Arial",sans-serif">Senior Benefits Analyst, Oregon Educators Benefit Board<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Arial",sans-serif">Health Policy and Analytics<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Arial",sans-serif"><a href="mailto:OEBB.Benefits@oregon.gov"><span style="color:#0563C1">OEBB.Benefits@oregon.gov</span></a><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Arial",sans-serif">Main: 888-469-6322<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:12.0pt;font-family:"Arial",sans-serif">Fax: 503-378-5832</span><o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Arial",sans-serif"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Gisha",sans-serif"><o:p> </o:p></span></p>
<p class="MsoNormal"><span style="color:#44546A"><img border="0" width="199" height="75" id="Picture_x0020_1" src="cid:image001.jpg@01D163DE.D9A73AC0" alt="cid:image001.jpg@01D10D96.C6B9DCE0"></span><span style="font-family:"Gisha",sans-serif"><o:p></o:p></span></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><span style="font-size:14.0pt;font-family:"Arial",sans-serif;color:#44546A">CONFIDENTIALITY NOTICE<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-size:14.0pt;font-family:"Arial",sans-serif;color:#44546A">This email may contain information that is privileged, confidential, or otherwise exempt from disclosure under applicable law. If you are not the addressee or it
appears from the context or otherwise that you have received this email in error, please advise me immediately by reply email, keep the contents confidential, and immediately delete the message and any attachments from your system.<o:p></o:p></span></p>
<p class="MsoNormal"><o:p> </o:p></p>
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