• ;J 

August 12, 2010 

Office of Consumer Infonnation and Insurance Oversight 

Department of Health and Human Services 

Attention: OCIIO-9991-IFC 

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 (pP ACA). 

- ::.....~

We " believe that every effort should be made to increase the number ofindividuals covered by 

PPACA, especially as ofJanuary 1,2014 when most ofthe refonn components (Insurance 

Exchanges, Subsidies, Tax Credits, etc.) come into play. 

The Ru1e provides the seven triggers that would revoke the grandfathered status of a group 

health plan: 

T • ': ') f. "."'. _ J:, ~ ; ," ~,: ", ,;" ,- t· .~~. : .•~,.. 1" \ .,; l ;, I'.,f././ .; t " 

• Mergers:or apqulsition~ withthe;.sol~,iR-tentio,iI;qf ~;iintain,irig,gpll~dfathe~istatus",,;;; • !." 

• Elimination of substantially all benefits to treat a particular condition 

, Elim'iiuitiori 'of b~iit!fits for any' element necessary to eliminate or diagnose a condition 

• ,Any chang~~o coinsurancelevel . ' ,'..... • i,' , 

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

• ' ,Co-payments (Medical Inflation +15% or $5 adjusted for medicalinflation) , 


.' '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 copaymeht level for primary c 

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 associ~ted with the plan. 

Other components of health care services can have a significant impact on the individual 

employe~,,~hicl1,can res1;1lt in ~ chcmge to their plan including: , 'f \> ~ j , ~, , " ,"'" - , ~' ..' • • 

~,' 'f" "'~. ~"l' ~ ""'," " . , :;".' I" '. f.'.," ' . 'I ~ " . ' < 

~ A' H~ubs'tantial change" to the provider network' 

!.1:~;.n·,;~ ~.'.;' J ,,' ,!~.. ::. ::;; :·:t'.j.'.... !:. ,; II. :·, ••1 '1';: ; =:; . 

~p.n~Q1l1ers beli~v~ .th~ir provi~e{)md$eproyid~J,';llet\vorl~)J.ssqc~~tt?d, wi~ any,plan is tin 

integral part ofthe health care benefits provided by the employer. Atennination 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 ofthe grandfather 

status. 

• 	

Even 

Change 

insured 

if the 

to 

in 

self-funded) 

issuer 

benefit 

or 

structure 

third-party 

. 

ofa 

administrator 

group health plan 

(TPA) 

remains 

(including 

largely 

movingfromfullythe 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 plaiI.· ...- - ~ . - ~ 

• 	 Significant change in care malJagementlauthorization 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 ofJanuary 2014 based on the current rules. While we understand 

the difficulty involved in making change, creating another hrrge 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 ihlpacfa 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. 

Gary C. Wanamaker, D.C. 


Michigan Association Of Chiropractors