Have questions about your employee benefits package? Contact AJG at or Benefits Guide 2017.

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1 Have questions about your employee benefits package? Contact AJG at or Benefits Guide 2017 New Hire

2 Stay connected Benefit Carrier Network/Group Number Medical BlueCross BlueShield of Texas Group # Network: BlueChoice PPO Customer Service Website Dental Ameritas Group # Network: Classic PPO Vision Ameritas/VSP Group # Network: VSP Choice Group Term Life and AD&D Short-Term Disability Long-Term Disability Voluntary Life and AD&D Employee Assistance Program (EAP) Health Savings Account (HSA) Cigna Group # SGM Cigna Group # SGD Cigna Group # SGD Cigna Group # SOK Cigna N/A Optum Bank N/A Flexible Spending Account (FSA) COBRA Administration Discovery Benefits Discovery Benefits N/A N/A Upland Software now has an online guide that will walk you through all of your benefits. To get help with choosing the best plan for you and your family, click here: 2

3 Enrollment Instructions How do I ENROLL? For 2017 you will make your benefit elections in UltiPro. You can access the system from any computer at As a reminder, your user name is your uplandsoftware.com address. If you haven t logged in to UltiPro before, your default password is your birthday (mmddyyyy). Once you re logged in: Click on the black Menu button at the top left of your screen and then select Life Event Click the I am a new employee link to get started Answer the What was the reason question by selecting Life Event-Hire from the drop down menu. Work your way through the steps, starting with entering dependents and beneficiaries (Date of birth and social security numbers are required for dependents) Medical, dental and vision are required elections - you ll need to either elect or waive coverage When you ve made your elections, the last page is the Confirm Your Elections or Changes page. Please make sure you are electing the coverage you want and that all of your covered dependents are listed on the medical, dental and vision plans. You can click the Print button to print this confirmation page for your records When you re satisfied with your elections, click the green Submit button UltiPro is available for your new hire enrollment for 31 days after your hire date. You need to login and complete the enrollment. Even if you are declining the health benefits, we need you to assign beneficiary for the basic life/ad&d coverage provided by Upland. Remember, your benefit elections will be effective from your hire date through December 31, If you have any question, please contact Jen Verzal (jverzal@uplandsoftware.com or ) or our benefits partner, Gallagher Benefit Services (austin.gbs.customerservice@ajg.com or ). 3

4 Benefit Advocates Arthur J. Gallagher & Co. is here to act as a liaison in your dealings with insurance carriers. If you are having problems getting claims paid or have questions regarding your coverage, let us deal with the insurance company for you. Please contact anyone at Arthur J. Gallagher & Co. with questions regarding your employee benefits package. Phone: (800) Fax: (512) Austin.GBS.CustomerService@ajg.com Hours of Operation: Monday - Friday 8:00 a.m. - 5:00 p.m. CST 4

5 Stay healthy Benefits OVERVIEW Upland Software proudly offers a comprehensive benefits package to eligible, employees who work 30 hours per week or more. The complete benefit package is briefly summarized in this brochure. Plan booklets and benefit summaries, which give you more detailed information about each of these programs, can be found through the Human Resources Department. What BENEFITS are available to me? Medical Dental Vision Flexible Spending Account (FSA) Health Savings Account (HSA) Group Term Life and AD&D Voluntary Life Short-Term Disability Long-Term Disability Employee Assistance Program (EAP) When am I ELIGIBLE for benefits? You and your dependents are eligible for benefits through Upland Software immediately, upon your date of hire. Eligible dependents are your spouse or domestic partner (same or opposite-sex), children up to age 26 and disabled dependents of any age. There are additional requirements to cover domestic partners. Please contact Human Resources for the required forms and information on the tax implications. MAKING CHANGES during the year Choose your benefits carefully. Medical, dental, vision and flexible spending account contributions are made on a pre-tax basis and per IRS regulations, contribution amounts cannot be changed unless you experience a qualified life event. Qualified life events include: Marriage or divorce; Death of your spouse/domestic partner or dependent Birth or adoption of a child: Your spouse/domestic partner terminating or obtaining new employment (that affects eligibility for coverage); You or your spouse/domestic partner switching employment status from full-time to part-time or vice versa (that affects eligibility for coverage); Significant cost or coverage changes; or Your dependent no longer qualifies as an eligible dependent. You must notify and submit any applicable forms and/or documentation to Human Resources within 30 days* of the event. Human Resources will review your request and determine whether the change you are requesting is allowed. Only benefit changes which are consistent with the qualified life event are permitted. *60 days if you, your spouse/domestic partner, or dependent child loses or gains coverage under Medicaid or a state Children s Health Insurance Program (CHIP). Important This document is an outline of the coverage proposed by the carrier(s). It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Your full Summary Plan Document (SPD) is made available through the Human Resources Department. The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific coverage issues can be directed to the Benefit Advocates at Gallagher Benefit Services, Inc., Austin.GBS.CustomerService@ajg.com 5

6 What are my options for MEDICAL COVERAGE? Administered by BlueCross BlueShield of Texas Comprehensive and preventive healthcare coverage plays an important part in protecting you and your family from the financial risks of unexpected illness and injury. A little prevention usually goes a long way -- especially in healthcare. Routine exams and regular preventive care provide an inexpensive review of your health. By identifying health problems early, you can reduce your risk of more serious illness and reduce out of pocket healthcare expenses. Upland Software offers you a choice of three medical plans. All three plan options utilize the same BCBS network and cover your preventive care at 100%. In addition, none of these plans require a Primary Care Physician (PCP) or for you to seek referrals in order to see a specialist. High Deductible Health Plan (HDHP) - You choose where you receive your medical services. All services on this plan will be subject to the deductible/coinsurance except preventive care. If you elect the HDHP you may also be eligible to take advantage of a Health Savings Account (HSA). Out-of-network benefits are available but you will save money by choosing network providers. Base and Buy-Up PPO Plans - You choose where you receive your medical services. These plans offer co-pays for your office visits and prescription drugs. All other expenses will be subject to the deductible/co-insurance. Out-ofnetwork benefits are available but you will save money by choosing network providers. 6

7 Stay healthy Benefit HDHP - HSA Plan Base PPO Plan Buy-Up PPO Plan Deductible (Calendar Year) In-Network Benefit** In-Network Benefit** In-Network Benefit** $5,000 Individual* $10,000 Family* Family Deductible Once one person hits $5,000 they will be covered at 100% The family as a whole will not be subject to more than $10,000. $1,500 per Individual $4,500 per Family Each individual in the family has their own deductible. Once three members have satisfied the deductible the family deductible has been met. $750 per Individual $2,250 per Family Each individual in the family has their own deductible. Once three members have satisfied the deductible the family deductible has been met. Coinsurance 100% after deductible 80% after deductible 80% after deductible Out-of-Pocket Maximum Includes deductible and co-pays (calendar year) $5,000 Individual $10,000 Family $4,000 Individual $12,000 Family $4,500 Individual $13,100 Family Hospital Services 100% after deductible 80% after deductible 80% after deductible Emergency Room (Emergency Situation) Facility Charges Physician Charges 100% after deductible 100% after deductible $100 co-pay 80% after deductible $100 co-pay 80% after deductible Urgent Care Facility 100% after deductible $50 co-pay $45 co-pay Physician Services Preventive Care (Office Visit) Primary Care Office Visit Specialist Office Visit Office & Outpatient Surgery Inpatient Visits Maternity Care Prescription Drugs (30 day supply) Generic Preferred Non-Preferred Medical Plan Monthly Premiums 100% 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% after deductible 100% $30 co-pay $45 co-pay 80% after deductible 80% after deductible 80% after deductible $20 co-pay $50 co-pay $75 co-pay 100% $25 co-pay $40 co-pay 80% after deductible 80% after deductible 80% after deductible $20 co-pay $35 co-pay $50 co-pay HDHP/HSA Plan Base PPO Plan Buy-Up PPO Plan Employee Pays Employer Pays Employee Pays Employer Pays Employee Pays Employer Pays Employee Only $0.00 $ $ $ $ $ Employee +Sp/Dm Prtnr $25.00 $ $ $ $ $ Employee + Child(ren) $20.00 $ $ $ $ $ Employee + Family $34.00 $1, $ $1, $ $1, * Includes a deductible reimbursement plan for the last $2,400 of individual coverage and the last $4,800 of family coverage; see page 5 for details. ** Please refer to the detailed plan summaries /SBCs for out-of-network coverage. While the Upland Software plans are administered by BlueCross BlueShield of Texas, the plans use the BlueCard PPO Program. BlueCard is a national program that links participating heath care providers with the independent BlueCross and BlueShield plans across the country, giving you access to one of the largest health care networks in America. Search for in-network providers in your area by logging on to and selecting Find a Doctor. Enter your location and select search. After updating your state of residence and the state in which you are searching, should the website change the health plan network to PPO, please leave this selection and continue your search. Please reach out to a Benefit Specialist at Gallagher Benefit Services if you need assistance with locating an in-network provider. 7

8 DEDUCTIBLE REIMBURSEMENT PLAN for participants of the HDHP/HSA plan Under Upland Software s Deductible Reimbursement Plan, members will be reimbursed for the last $2,400 of your $5,000 deductible. If you are covering dependents you will be eligible for up to $4,800. (Either for 2 separate individual claims or cumulative family claims.) For example: If you have surgery and pay your entire $5,000 deductible you may file a claim and be reimbursed $2,400. In order to receive reimbursement for qualified expenses, you need to submit the Explanation of Benefits (EOB) you receive from BlueCross BlueShield. The EOB shows the deductible amount paid by you that is over $2,600. A copy of the EOB and a claim form should be submitted to Discovery Benefits at: Fax: customerservice@discoverybenefits.com Online: Frequently Asked Questions Q: Will the Reimbursement Plan reimburse me for charges not covered by BCBS? A: No, the Reimbursement Plan will follow the guidelines of BCBS. So, if a procedure is not allowed or an expense is not eligible for claim payment, then a reimbursement will not be issued. Q: What if I lose my EOB but I have a receipt from the provider? A: We will only reimburse from EOBs. You can obtain another copy from BCBS by logging on to their website ( or calling Q: I have exceeded $2,600 in expenses but haven t met my deductible yet. Am I eligible to submit a claim? A: Yes, you may start submitting claims as soon as you have exceeded $2,600. Q: I am on the Base PPO Plan. May I submit to be reimbursed for my deductible? A: No. This plan is only available to participants on the HDHP/HSA Option. 8

9 Stay healthy Show me those pearly whites! DENTAL Administered by Ameritas Good oral health enhances overall physical health, appearance, and mental well-being. Problems with the teeth and gums are common and easily treated health problems. Your dentist also performs a cancer screening as part of your preventive care. Keep your teeth healthy and your smile bright with the Upland Software dental plan. Benefit MAC Plan Network Only PPO Plan See any Dentist Network Classic PPO Classic PPO Type I - Preventive Services Cleanings (4 in 12 months), fluoride treatments (13 & under), oral exams (2 in 12 months), sealants, x-rays Type II - Basic Services Fillings, simple extractions, root canals, scaling and root planing, surgical extractions 100% after a $10 co-pay 100% after deductible 80% after deductible Type III - Major Services Bridges, dentures, inlays/onlays, implants, single crowns 60% after deductible 50% after deductible Annual Deductible $50 Individual $150 Family Annual Maximum $1,500 Maximum Rollover Account Child Orthodontia (under age 19) Dental Plan Monthly Premiums If you use less than $750 per year you get to roll-over $250 to use in future years Employee Pays 50% to $1,500 per lifetime Employer Pays Employee Only $7.00 $31.07 Employee +Sp/Dm Prtnr $21.00 $56.08 Employee + Child(ren) $23.00 $78.41 Employee + Family $32.00 $ MAC Plan: If you choose this option you must choose a network dentist. PPO Plan: You may choose any dentist but you may be subject to allowable amount limits if your dentist does not participate in the dental plan network. 9

10 I can see clearly now...vision Administered by Ameritas/VSP Regular eye examinations not only determine your need for corrective eyewear but also may detect general health problems in their earliest stages. Protection for the eyes should be a major concern to everyone, even if you do not wear glasses or contact lenses. Benefit In-Network Non-Network Network VSP Choice Network Eye Exam $25 co-pay Up to $45 reimbursement Frames/Lenses Single Vision $25 co-pay Up to $30 reimbursement Bifocal Lenses $25 co-pay Up to $50 reimbursement Trifocal Lenses $25 co-pay Up to $65 reimbursement Frames $120 allowance / 20% off remaining balance Up to $70 reimbursement Contacts - in lieu of glasses $120 allowance Up to $120 reimbursement Exam Frequency Every 12 months Every 12 months Lens Frequency Every 12 months Every 12 months Frames Frequency Every 24 months Every 24 months Vision Plan Monthly Premiums Employee Pays Employer Pays Employee Only $4.00 $3.60 Employee +Sp/Dm Prtnr $6.00 $6.08 Employee + Child(ren) $6.00 $8.01 Employee + Family $10.00 $

11 Stay smart Who can open a Health Savings Account (HSA) and how does it work? Administered by Optum Bank An HSA has triple tax benefits! The money goes in tax-free, the money earns interest tax-free and your withdrawals for qualified medical expenses (including any earnings) are tax-free. If you elect the HDHP medical plan, you may be able to open a Health Savings Account (request additional HSA eligibility requirements through the Human Resources Department). An HSA is a tax-advantaged personal savings account that works in conjunction with a High Deductible Health Plan (HDHP). You can use the funds to pay for current AND future medical expenses. The money you don t spend rolls over from year to year and is yours to keep, even if you leave Upland Software. Your pre-tax contributions are made each pay period and you may change your contribution throughout the year Maximum Annual Contribution Employee Only $3,400 Employee + Dependent(s) $6,750 If you are age 55 or older you are allowed to contribute an additional $1,000 each year. For participants who are only eligible for part of the year: You may contribute the full annual maximum to your HSA account. If you fail to remain eligible for a 13-month period beginning December 1st of the year in which you become eligible and ending on December 31st of the following year, your excess contributions will be subject to federal income tax and subject to a 6% excise tax. Please consult your tax advisor with questions. You may not contribute to an HSA if you or your spouse participate in an FSA (unless limited use). How can I save with a Flexible Spending Account (FSA)? Administered by Discovery Benefits You can save money on your healthcare and/or dependent care expenses with an FSA. You set aside funds each pay period on a pre-tax basis and use them tax-free for qualified expenses. You pay no federal income or Social Security taxes on your contributions to an FSA. (That s where the savings comes in.) Your FSA contributions are deducted from your paycheck before taxes are withheld, so you save on income taxes and have more disposable income. When you have an eligible healthcare or dependent care expense, you can pay for it with tax-free money. Healthcare FSA - $2,600 (PPO participants only) Dependent Care FSA - $5,000 (combined family maximum per calendar year) Claims for the current plan year must be submitted within 90 days after the plan year ends in order to be eligible for reimbursement. 11

12 Stay secure Why is LIFE INSURANCE important? How much coverage can I elect? Administered by Cigna Life Insurance provides financial security for the people who depend on you. Your beneficiaries will receive a lump-sum payment if you die while employed by Upland Software. The company provides basic life insurance of 2 times your annual earnings up to $350,000, at no cost to you. Accidental Death and Dismemberment (AD&D) insurance Administered by Cigna Accidental Death and Dismemberment (AD&D) insurance provides payment to you or your beneficiaries if you lose a limb or die in an accident. Upland Software provides AD&D coverage of 2 times your annual salary up to $350,000. This coverage is in addition to your company-paid life insurance described above. VOLUNTARY LIFE insurance Administered by Cigna You can purchase additional life insurance coverage to provide you and your family financial security through payroll deductions. You can elect additional life insurance for: Yourself: In increments of $10,000, up to a maximum of 5 times your salary or $500,000; guarantee issue of $100,000*. Your Spouse/Domestic Partner: In increments of $5,000 up to the lesser of employee s amount or $250,000; guarantee issue of $50,000*. Your Child(ren): In increments of $5,000 up to $25,000. Live birth to 6 months limited to $250 in coverage For the cost of this coverage, please refer to the chart below. Voluntary Life - (Cost per $1,000 of coverage) Age Employee Rate (includes AD&D) Spouse Rate <25 $0.08 $ $0.09 $ $0.11 $ $0.12 $ $0.145 $ $0.203 $ $0.295 $ $0.525 $ $0.789 $ $1.491 $ $2.399 $ $4.487 $4.457 Child(ren) Rate $0.20 per $1,000 (All Children) Spouse cost will be based on your spouse s age 12 *Please note that guarantee issue amounts for you and your spouse will only apply during your initial enrollment period. If you are signing up for the first time you will be subject to Evidence of Insurability (EOI) and coverage may be declined. The EOI form can be completed by clicking here.

13 Stay secure What is DISABILITY INSURANCE and how can it help me? Administered by Cigna Short and Long Term Disability coverage provide income replacement if you become disabled and are unable to work. You pay the imputed income on these benefits which provides you with a tax-free benefit when you go out on disability. Both Short and Long-Term Disability payments are reduced by other income received during your disability, such as Social Security payments and state disability benefits. Short-term disability If you become disabled, you can receive payment from the plan for up to 11 weeks. You will receive 60% of your weekly earnings up to $1,500 per week. You must be disabled for 14 consecutive days before your benefit begins paying. Long-term disability If you are still disabled after 11 weeks, you may become eligible for long-term disability. Long-term disability begins after 90 days of disability and continues until you recover or reach your Social Security Normal Retirement Age, whichever occurs first. You can receive 60% of your monthly earnings up to a maximum of $10,000 per month. PRE-EXISTING CONDITION limitations A pre-existing condition is a sickness or physical condition for which you were diagnosed with, or treated for in the 3 months prior to your effective date. These conditions will be excluded on the long term disability plan for the first 12 months. Please note that pregnancy is considered a pre-existing condition. 13

14 Additional benefits EMPLOYEE ASSISTANCE PROGRAM (EAP) Personal issues, we can help. Your EAP can provide assistance with parenting concerns, relationship issues, legal and financial issues, moving and relocation, stress and depression, just to name a few. The best part?...it s all at no cost to you! EAP resources are available to you and all of your dependents, and services provided are COMPLETELY CONFIDENTIAL. Access benefits 24 hours a day, 7 days a week. Call: Online: HOLIDAY SCHEDULE Holiday New Year s Day MLK Day President s Day Memorial Day Independence Day Labor Day Thanksgiving Day Day after Thanksgiving Christmas Christmas Date Monday, January 2 nd Monday, January 16 th Monday, February 20 th Monday, May 29 th Tuesday, July 4 rd Monday, September 4 th Thursday, November 23 rd Friday, November 24 th Monday, December 25 th Tuesday, December 26 th 14

15 Important Legal Notices This book highlights some of the main features of your benefit programs, but does not include all plan rules, features, limitations or exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be any inconsistencies between this book and the legal plan documents, the plan documents are the final authority. Upland Software reserves the right to change or discontinue its benefit plans at any time. HIPAA Privacy Notice HIPAA requires Upland Software to notify you that a privacy notice is available upon request. Please contact Human Resources if you have any questions or require a copy. The Women s Health and Cancer Rights Act The Women s Health and Cancer Rights Act of 1998 requires group health plans that provide coverage for a mastectomy to provide coverage for certain reconstructive services. This law also requires that written notice of the availability of the coverage be delivered to all plan participants upon enrollment and annually thereafter. This language serves to fulfill that requirement for this year. These services include: Reconstruction of the breast upon which the mastectomy has been performed; Surgery / reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment for physical complications during all stages of mastectomy, including lymphedemas. In addition, the plan may not: Interfere with a participant s rights under the plan to avoid these requirements; or Offer inducements to the healthcare provider, or assess penalties against the provider, in an attempt to interfere with the requirements of the law. However, the plan may apply deductibles, coinsurance, and co-payments consistent with other coverage provided by the plan. 15

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17 Medicare D Notice Important Notice from Upland Software About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Upland Software and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Upland Software has determined that the prescription drug coverage offered by the Upland Software Medical Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Upland Software coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Upland Software coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Upland Software and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. 17

18 Medicare D Notice For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Upland Software changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Date: January 2017 Name of Entity/Sender: Upland Software Contact--Position/Office: Human Resources Department Address: 401 Congress Ave, Ste 1850 Austin, TX Phone Number: CMS Form CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland

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