https://fdms.erulemaking.net/...y/component/submitterInfoCoverPage?Call=Print&PrintId=0900006480b302fc&Comment=true[8/16/2010 1:16:29 PM]

PUBLIC SUBMISSION

As of: August 16, 2010

Received: August 13, 2010

Status: Pending_Post

Tracking No. 80b302fc

Comments Due: August 16, 2010

Submission Type: Web

Docket: HHS-OS-2010-0015

Group Health Plans and Health Insurance Coverage: Interim Final Rules for Relating to Status as a Grandfathered

Health Plan under the Patient Protection and Affordable Care Act

Comment On: HHS-OS-2010-0015-0001

Group Health Plans and Health Insurance Coverage: Interim Final Rules for Relating to Status as a Grandfathered

Health Plan under the Patient Protection and Affordable Care Act

Document: HHS-OS-2010-0015-DRAFT-0047

Comment on FR Doc # N/A

Submitter Information

Name: Heidi Siegfried

Organization: New Yorkers for Accessible Health Coverage

General Comment

New Yorkers for Accessible Health Coverage (NYFAHC) is a statewide coalition of 53 voluntary health organizations

and allied groups who serve and represent people with chronic illnesses and disabilities, including mental illness

for whom access to affordable, accessible comprehensive health coverage is essential to maintaining their well

being. We appreciate this opportunity to comment on the proposed rules for implementing the grandfathering

provisions of the Affordable Care Act.

We understand that the American people were told that they can “keep what they have”. At the same time, “what

they have” could be improved by being subject to the consumer protections and quality standards of the Act, so

we support setting reasonable well-defined limits on a health plan’s ability to maintain grandfathered status to

ensure that the law fulfills ts promise for as many consumers as possible. 

Small changes to an insurance plan can mean entirely different coverage to a person or group. Given our

constituency, we particularly appreciate the proposal that a plan lose grandfathered status if it eliminates

substantially all benefits to treat or diagnose a specific condition, no matter how rare, including eliminating

benefits for an element of treatment. We would recommend that elimination of benefits which are not designed to

treat or diagnose a specific condition, but which are designed to keep a participant healthy, such as preventative

benefits or wellness programs be included as well. In general, whether a change functions to eliminate access to

treatment for a group or individual is a good standard to use in considering what changes should cause a plan to

lose its grandfathered status. 

We know that the kinds of cost shifting onto the consumer through increased cost-sharing, deductibles or out ofpocket-limits and co-pays can deter or prevent access to care. We realize that you have attempted to take a

middle road with regard to these provisions and we hope

Attachments

HHS-OS-2010-0015-DRAFT-0047.1: Comment on FR Doc # N/A
New Yorkers for Accessible Health Coverage – August 13, 2010 

August 13, 2010 

Office of Consumer Oversight 

Department of Health and Human Services 

Hubert H Humphrey Building, Room 445-G 

200 Independence Avenue, SW 

Washington, D.C. 20201 

Re: HHS-05-2010-0015-0004 

To Whom it May Concern: 

New Yorkers for Accessible Health Coverage (NYFAHC) is a statewide coalition 

of 53 voluntary health organizations and allied groups who serve and represent 

people with chronic illnesses and disabilities, including mental illness for whom 

access to affordable, accessible comprehensive health coverage is essential to 

maintaining their well being. We appreciate this opportunity to comment on 

the proposed rules for implementing the grandfathering provisions of the 

Affordable Care Act. 

We understand that the American people were told that they can “keep what 

they have”. At the same time, “what they have” could be improved by being 

subject to the consumer protections and quality standards of the Act, so we 

support setting reasonable well-defined limits on a health plan’s ability to 

maintain grandfathered status to ensure that the law fulfills ts promise for as 

many consumers as possible. 

Small changes to an insurance plan can mean entirely different coverage to a 

person or group. Given our constituency, we particularly appreciate the 

proposal that a plan lose grandfathered status if it eliminates substantially all 

benefits to treat or diagnose a specific condition, no matter how rare, including 

eliminating benefits for an element of treatment. We would recommend that 

elimination of benefits which are not designed to treat or diagnose a specific 

condition, but which are designed to keep a participant healthy, such as 

preventative benefits or wellness programs be included as well. In general, 

whether a change functions to eliminate access to treatment for a group or 

individual is a good standard to use in considering what changes should cause 

a plan to lose its grandfathered status. 

We know that the kinds of cost shifting onto the consumer through increased 

cost-sharing, deductibles or out of-pocket-limits and co-pays can deter or 

prevent access to care. We realize that you have attempted to take a middle 

road with regard to these provisions and we hope that you have struck the 

right balance. 

The Departments have sought advice on what other plan changes should forfeit 

grandfathered status. Our recommendations follow: 
New Yorkers For Accessible Health Coverage 2 

Changes to Plan Structure 

Changes to a plan’s basic design, such as from a PPO to an HMO, or an EPO, or 

other closed network structure should trigger a loss of grandfathered status. 

Such changes can have a significant impact on access to care by placing 

additional barriers for participants attempting to access specialists, forcing 

them to change providers with possible disruptions in care. New York has 

chosen to use an EPO for it Pre-existing Condition Insurance Plan and we are 

very concerned about how a closed network will work for this population. 

Network 

NYFAHC has long been concerned about network adequacy and we believe that 

significant changes to a plan’s provider network should result in loss of 

grandfathered status for the plan. A network change can mean months of 

delayed treatment as an individual is searching for a provider in network and 

waiting for a new patient appointment. If a plan drops all providers within a 

certain subspecialty in a region, such that a consumer does not have access to 

a choice of specialist within a reasonable travel time or distance, the plan has 

essentially eliminated the benefits to treat or diagnose a specific condition. 

Such a change should result in a loss of grandfathered status. 

Formularies 

For plan members with chronic orserious illnesses and disabilities, changes in 

the design and administration of drug benefits can result in un-affordable 

increases in out-of-pocket costs, interruptions or delays in care and can amount 

to an elimination of substantially all benefits to diagnose or treat a particular 

condition. Accordingly we would recommend that the following changes 

operate to eliminate grandfathered status. 

1. Restricting the formulary overall by shifting from an open formulary to a 

closed or tiered formulary; 

2. The establishment of new, higher, or specialty tiers with the effect of 

increasing enrollees’ cost-sharing requirements; 

3. The elimination of one or more tiers with the effect of increasing certain 

enrollees’ cost-sharing requirement; 

4. The re-arrangement of tiers among a covered class of drugs resulting in a 

reduction in the total number of drugs with the lowest cost-sharing 

requirement; 

5. Restricting a formulary to ‘generics only’; 

6. Requiring mail-order delivery for some or all drugs on the formulary. 

7. Eliminating specialty pharmacy support services for certain plan members 

with special needs; 
New Yorkers For Accessible Health Coverage 3 

8. Imposing or lengthening the moratorium period before new therapies can be 

added to the formulary. 

Enforcement Mechanism 

The interim final rules do not provide a mechanism for consumers to challenge 

a plan’s grandfathered status. The notice set forth in the interim final rule does 

not advise a consumer which agency will be enforcing the rules nor is any 

agency given the authority to strip a plan of its grandfathered status as a result 

of the investigation of a consumer complaint. Without a designated authority 

to enforce the regulations, there is not a way for a consumer to obtain relief if 

a plan takes an action that, under the rules, could result in the loss of 

grandfathered status. Consumers, providers, non-profit advocacy 

organizations, and state agencies should all have standing to challenge a plan’s 

grandfathered status and we strongly urge that any hearings held on a plan’s 

status be conducted locally so that consumers, other stakeholders, and the 

public can attend and testify at them 

We appreciate this opportunity to comment these proposed rules. Thank you 

for your attention in this matter. 

Sincerely, 

Heidi Siegfried, Esq. 

Program Director