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LEGAL PROCESSING DIVISION

PUBLICATION & REGULATIONS
BRANCH

As of: September 02, 2010

PUBLIC Received: August 11, 2010

Posted: September 02, 2010
SUBMISSION Comments Due: August 16, 2010

Submission Type: Web

Docket: IRS-2010-0010
Group Health Plans and Health Insurance Coverage Rules Relating to Status as a Grandfathered
Health Plan Under the Patient Protection and Afforable Care Act

Comment On: IRS-2010-0010-0001
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: IRS-2010-0010-0585
Comment on FR Doc # 2010-14488

RT

Submitter Information

Name: Peter Rom
Address:
China, MI,

Email: drpeterom@gmail.com
—

General Comment

See attached file(s)

Attachments

IRS-2010-0010-0585.1: Comment on FR Doc # 2010-14488

https://fdms.erulemaking.net/fdms-web-agency/component/submitterInfoCoverPage?Call=P... 9/2/2010


Aug, 11, 2010

Dr. Peter C. Rom
1605 Fred Moore HWY
St. Clair, MI 48079

Office of Consumer Information and Insurance Oversight
Department of Health and Human Services

Attention: OCIIO-9991-1FC

P.O. Box 8016

Baltimore, MD 21244-1850

Re: Interim Final Rule for Group Health Plans and Health Insurance Coverage Relating to Status as a
Grandfathered Health Plan Under the Patient Protection and Affordable Care Act

Below are our comments regarding the Interim Final Rule for Group Health Plans and Health Insurance
Coverage Relating to Status as a Grandfathered Health Plan Under the Patient Protection and Affordable
Care Act (PPACA).

We believe that every effort should be made to increase the number of individuals covered by PPACA,
especially as of January 1, 2014 when most of the reform components (Insurance Exchanges, Subsidies,
Tax Credits, etc.) come into play.

The Rule provides the seven triggers that would revoke the grandfathered status of a group health plan:

¢ Mergers or acquisitions with the sole intention of maintaining grandfather status

¢ Elimination of substantially all benefits to treat a particular condition

e Elimination of benefits for any element necessary to eliminate or diagnose a condition
e Any change to coinsurance level

e Fixed-amount cost-sharing (Deductibles/OOP) Inflation +15%

© Co-payments (Medical Inflation +15% or $5 adjusted for medical inflation)

e Employer contribution (> 5% reduction in Employer Contribution)

While relatively straightforward, these guidelines may still result in some confusion to the marketplace
in their application. For example, if an employer raised the copayment level beyond the maximum in
one area (i.e. outpatient services) but retained the copayment level for primary care doctor visits, does
that mean a loss of grandfather status? Clarity will be critical both for the employer and the employee.

The average consumer has a broad definition of “benefits.” Consumers view their health plan beyond the
covered benefits, cost sharing, and the contribution levels associated with the plan. Other components of
health care services can have a significant impact on the individual employee, which can result in a
change to their plan including:

e A “substantial change” to the provider network


Consumers believe their provider and the provider network associated with any plan is an
integral part of the health care benefits provided by the employer. A termination of a hospital
system or specific provider group sometimes has significant impact on the employee population
and should be viewed as a substantial change to the plan itself. As a guideline, we would suggest
any change in the provider network impacting over 50% of the employee population (nationally
or locally) should result in a loss of the grandfather status.

© Change in issuer or third-party administrator (TPA) (including moving from fully-insured to
self-funded)

Even if the benefit structure of a group health plan remains largely the same, a change in
administration of the plan requires new communication, new processes, and new requirements on
the part of an employee and the employer. Moving from a fully-insured to a self-funded status or
changing administrators requires new processes and legal agreements for the group health plan.
These transitions are not daily or regular events and should be considered a change in the group
health plan.

© Significant change in care management/authorization requirements

The processes consumers need to follow to receive care are a significant component of their
perceptions of their health benefits plan. Changing notification requirements, requiring referrals,
or other care management strategies involved in the delivery of care should also be considered as
a change to the plan. This may prevent group health plans from maintaining their grandfather
status by not necessarily eliminating a benefit, but making it difficult to receive by changing the
care management process around it.

Even by the most optimistic estimates, a substantial portion of the employee population will remain
outside the PPACA as of January 2014 based on the current rules. While we understand the difficulty
involved in making change, creating another large sub-population of excluded individuals will only add
to costs, increase confusion, and mitigate the potential impact of the legislation. This only adds to the
uncertainty surrounding the $143 billion in deficit reduction projected by the Congressional Budget
Office (CBO) when the process began.

We believe that any changes related to the areas listed above should also result in a loss of grandfather
status as these are changes that heavily impact a patient’s healthcare benefits. The Rule needs to be
clear, reasonable, and with no ambiguities involved in determining whether a group health plan is “in or
out.” The decisions we make today will determine the outcomes for tomorrow. We may need to make
some difficult decisions to create a sustainable health care system that will support a growing economy
in the future. That means getting as many citizens across the country participating at the beginning to
make it work and delivering on its promises to retain their support.

Thank you for the opportunity to comment on this regulation.

Dr. Peter C. Rom
Marshall Family Chiropractic