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AUG 2 F 

LEGAL PROCESS1,~G DIVISION 


PUBLICATION &. REGULATIONS 


BRANCH 


As of: August 26, 2010 

Received: August 10, 2010 

Status: Posted 

Posted: August 26, 2010 

Tracking No. 80b2da35 

PUBLIC 


SUBMISSION 
 Comments Due: August 16, 2010 

Submission Type: Web 

Docket: IRS-2010-001O 

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-201O-001O-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-2010-001O-0433 

Comment on FR Doc # 2010-14488 

Submitter Information 

Name: Nathan M Unterseher 

Address: 

1260 E Tipton St 

Seymour, IN, 47274 

Email: drn8@live.com 

Phone: 812-524-2273 

Fax: 812-522-9852 

Organization: Jackson County Chiropractic 

---------------------------------------------------------------,--­

General Comment 

See attached file(s) 

Attachments 

IRS-2010-0010-0433.1: Comment on FR Doc # 2010-14488 

https:llfdms.erulemaking.netlfdms-web-agency Icomponentlsubmitter InfoCover Page?Call=... 8/26/2010 
NATHAN M. UNTERSEHER, D.C. 

1260 East Tipton Street Jackson'Coun~y Seymour, Indiana 47274 

chiropractic (812) 524-2273. Fax (812) 5:~2-9852

www.MyDCGroup.com 

August 10, 2010 

Office of Consumer Information 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 (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 

• Elimination of benefits for any element necessary to eliminate or diagnose a condition 

• Any change to coinsurance level 

• Fixed-amount cost-sharing (DeductibleslOOP) Inflation +15% 

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

• 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 empl.oyee. 

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: 
• 	 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 !ltatus 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 rt~ferrals, 

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 grandf,lther 

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 changes, 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. 

Nathan M. Unterseher, DC 

Jackson County Chiropractic