COALITION FOR WHOLE HEALTH 

August 16, 2010 

Mr. Jim Mayhew 

Office of Consumer Information and Oversight 

Department of Health and Human Services 

Attention: OCIIO-9991-IFC 

P.O. Box 8016 

Baltimore, MD 2144-1850 

RE: Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to 

Status as a Grandfathered Health Plan under the Patient Protection and Affordable Care Act

Dear Mr. Mayhew: 

Thank you for this opportunity to provide comments to the Departments of Labor, Health and Human 

Services, and the Treasury (the Departments) regarding the interim final rule on grandfathered health 

plans under the Patient Protection and Affordable Care Act (PPACA). On behalf of the Coalition for 

Whole Health, a coalition of national organizations advocating for improved coverage for and access 

to mental health and substance use disorder prevention, treatment, rehabilitation, and recovery 

services, we strongly support the goals of healthcare reform to ensure that all Americans have access to 

high quality, affordable health care, including mental health and addiction care. We appreciate the 

opportunity to submit comments on the interim final rule on grandfathered plans. 

Below is our response to the proposed regulations. We are particularly pleased that the Departments: 

1. Require that Grandfathered Plans Comply with the Mental Health and Addiction Parity 

Provisions of the PPACA 

2. Require that Plans Adhere to Certain Consumer Protective Practices to Retain Their 

Grandfathered Status 

3. Acknowledge that State Laws Providing Greater Consumer Protections than the PPACA 

Remain in Effect 

1. Requirement that Grandfathered Plans are Subject to the Mental Health and Addiction Parity 

Provisions of the PPACA 

First, we applaud the Departments for requiring that grandfathered plans must comply with the mental 

health and addiction parity provisions of the PPACA. These provisions, found in Title I, Subtitle D, 

Part II, Section 1311 of the PPACA, incorporate by reference the Paul Wellstone and Pete Domenici 

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and require that qualified health 

plans under the PPACA must adhere to the provisions of MHPAEA. Moving forward, we ask that the 

Departments continue to explicitly affirm that MHPAEA requirements apply to grandfathered plans 

and to make the monitoring and enforcement of these requirements a high priority. 
We thank the Departments for making clear that grandfathered plans are required to comply with the 

MHPAEA. Section 2590.715-1251(c)(2) of the Interim Final Rules states that “a grandfathered health 

plan must comply with the requirements of the PHS (Public Health Services) Act, ERISA (Employee 

Retirement Income Security Act) and the Internal Revenue Code applicable prior to the changes 

enacted by the Patient Protection and Affordable Care Act.” The Paul Wellstone and Pete Domenici 

Mental Health Parity and Addiction Equity Act (MHPAEA) became law in October 2008, amending 

Section 712 of ERISA, Section 2705 of the Public Health Service Act, and Section 9812 of the Internal 

Revenue Code of 1986. Further, the guidance preceding the interim final rule clearly states that, “the 

mental health parity provisions...continue to apply to grandfathered health plans.” 

We were extremely pleased with the passage of the MHPAEA, and with it the promise of eliminating 

barriers that have kept thousands of individuals with substance use disorders and mental illnesses from 

receiving critically important treatment services. We thank the Departments for clarifying that 

grandfathered plans are subject to the provisions of MHPAEA and ask, as you work to inform plans, 

stakeholders and the public about the requirements of the PPACA and the regulations implementing 

the new law, that this information clearly and explicitly identifies the law’s mental health and addiction 

parity requirements and the new rights and benefits afforded to plan participants by the ongoing 

regulatory requirements. 

2. Requirement that Plans Adhere to Certain Consumer Protective Practices to Retain Their 

Grandfathered Status 

The interim final rule affirms that a plan will lose its grandfathered status if it makes certain major 

changes that disadvantage enrollees. We urge the Departments to create strong enforcement 

mechanisms to strip plans of their grandfathered status if they violate the requirements for maintaining 

that status. 

We applaud the Departments for requiring plans to comply with a number of critically important 

consumer protections in order to retain their status as grandfathered plans. We are particularly pleased 

that the interim final rule identifies the following practices as those that would cause a plan to lose its 

grandfathered status: 

 Eliminating all or substantially all benefits necessary to diagnose or treat a particular condition, 

including a mental health or substance use condition 

 Changes in cost-sharing, including coinsurance, copayments and deductibles, that impose 

unreasonable cost-sharing requirements on individuals 

 Changes in employer contribution rates 

We urge the Departments to issue additional guidance clarifying that other major changes plans make 

that would have a significant harmful impact on access to care would also trigger the loss of 

grandfathered status. These activities include: 

 Imposing additional requirements that make it more difficult for individuals to afford and 

access certain health services and providers, including care for mental illness and substance use 

disorders 

 Making major changes in provider networks that serve to further limit the number of providers 

(including primary care, mental health and addiction service providers) in a plan 

 Instituting major changes to the administration of prescription drug benefits and drug 

formularies; this would include restricting the formulary by shifting from open formulary to a 
closed or tiered formulary, changing the formulary in a way that increases enrollees’ costsharing requirements, and additional practices that significantly restrict enrollees’ access to 

medications, including those prescribed for the treatment of mental health and substance use 

disorders 

We also ask for clarification from the Departments that health plans that drop coverage for dependents 

or spouses are in violation of the grandfathered plan requirements. 

3. Acknowledgement that State Laws Providing Greater Consumer Protections than the PPACA 

Remain in Effect 

We applaud the recognition by the Departments that grandfathered plans should be given the flexibility 

to enhance their scope of services, to make voluntary changes to increase benefits, to conform to 

required legal changes, and to voluntarily adopt additional consumer protections in the PPACA. It is 

also critically important that State laws that impose requirements on health insurance issuers that are 

stricter than the requirements of the PPACA are not superseded by the Act. We applaud the 

Departments for explicitly stating that these more stringent State laws regulating health insurance 

issuers remain in effect and are not preempted by the new federal law. 

Thank you again for the opportunity to provide comment on the interim final rule on grandfathered 

plans. We understand that the purpose of grandfathering plans is to provide a smooth transition 

allowing individuals who like their current health insurance to keep it during a period of rapid 

transition in our healthcare system, rather than to create a situation where certain plans can be 

permanently exempted from the requirements of reform. Although grandfathered plans remain exempt 

from a number of vital reforms of the PPACA, in the long term we look forward to working with the 

Departments to ensure that all small group and individual plans must comply with the PPACA’s strong 

essential benefits requirements, including those that require mental health and substance use disorder 

benefits at parity with those of other medical and surgical benefits, and that other critically important 

reforms also eventually apply to all plans. 

We appreciate the opportunity to comment on interim final regulations related to grandfathered plans 

under the healthcare reform law. Please contact us if you have any questions or if we can be of further 

assistance on this matter. 

Sincerely, 

Alcoholism and Substance Abuse Providers of New York State 

American Art Therapy Association 

American Association for Marriage and Family Therapy 

American Foundation for Suicide Prevention/SPAN USA 

American Mental Health Counselors Association 

American Nurses Association 

American Psychiatric Association 

American Psychoanalytic Association 

American Psychological Association 

Anxiety Disorders Association of America 

Association for Ambulatory Behavioral Healthcare 

Bazelon Center for Mental Health Law 
Center for Clinical Social Work 

Clinical Social Work Association 

Community Advocates Public Policy Institute 

Community Anti-Drug Coalitions of America 

DC Recovery Community Alliance 

Depression and Bipolar Support Alliance 

Hazelden Foundation 

Legal Action Center 

Mental Health America 

NAADAC, The Association for Addiction Professionals 

National Alliance on Mental Illness 

National Association for Children's Behavioral Health 

National Association of Addiction Treatment Providers 

National Association of County Behavioral Health and Developmental Disability Directors 

National Association of Drug Court Professionals 

National Association of State Mental Health Program Directors (NASMHPD) 

National Council for Community Behavioral Healthcare 

National Council on Alcoholism and Drug Dependence - Maryland Affiliate 

National Disability Rights Network 

Open Society Institute - Baltimore 

PAR - People Advocating Recovery 

State Associations of Addiction Services 

TeenScreen National Center for Mental Health Checkups 

Therapeutic Communities of America 

Treatment Research Institute