August 12, 20 I 0 

Office ofConsumer Information and Insurance Oversight 

Department ofHealth and Human Services 

Attention: OCII0-9991-IFC 

P.O. Box 8016 

Baltimore, MD 21244-1850 

Re: Interim Final Ru1e 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 Ru1e for Group Health Plans and 

Health Insurance-Coverage"Relatiri:g 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 PPA CA, especially as ofJanuary 1, 2014 when most ofthe reform 

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: 

• Mergers or acquisitions with the sole intention ofmaintaining grandfather status 

'j'.'; Elimination ofsubstailtially all benefits't6 treat a particular condition 

'.' :Eliminati~n of behefits'for'any ele~ent!~~cessruY to ~limi~~te q~ diagnose!a . 

condition . 

• Any change to coinsurance level 

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

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

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

. . 'WhileIelalively 'straightfoiward;'tn:ese guideliiies 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 ofgrandfather 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 as'igDiflcant iinpact on the 

individual. employee, which 'can'result in a change to their plan 'including: .. 

. ',! J 

• A "substantial change" to the provider network 
Consumers believe their provider and the provider network associated with any 

plan is an integral part ofthe health care benefits provided by the employer. A 

termination ofa 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% ofthe employee population 

(nationally or locally) should result in a loss ofthe grandfather status. 

• 	 Change in issuer or third-party administrator (I'P A) (including moving from 


folly-insured to self-funded) 


Even ifthe benefit structure of a group health plan remains largely the same, a 

change in administration ofthe plan requires new communication, new processes, 

--. and new requirementson the parto! a.i1employee-and theemployer. 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 oftheir perceptions oftheir 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 ofthe 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 large subpopulation of excluded individuals will only add to costs, increase confusion, and 

mitiga!e t~ep'?tential impact ofthe 1~gi~l~i5!!1.- Ihi~only_addsJoth~ unc_ertainty__ 

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 

ofgrandfather 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. 
Keith L. Kermeen, D.C. 

Kermeen Chiropractic 

218 South 10th Street 

Escanaba, MI 49829 

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