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IV _ r ( , l 

LEOAL PROCESS GDIVISION 

PUBLICATION & REGULATIONS 

8IV\NCH 

PUBLIC 

SUBMISSION 

Asof: August 26, 2010 

Received: August 10, 2010 

Status: Posted 

Posted: August 26, 2010 

Tracking No. 80b2d354 

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-2010-0010-0465 

Comment on FR Doc # 2010-14488 

Submitter Information 

Name: Anthony R Galante 

Address: 

2210 Huntington Dr N 

Algonquin, IL, 60102 

Submitter's Representative: Anthony Galante 

Organization: Algonquin Chiropractic 

Government Agency Type: Federal 

Government Agency: HRSA 

General Comment 

See attached file(s) 

Attachments 

IRS-2010-0010-0465.1: Comment on FR Doc # 2010-14488 

https:llfdms.erulemaking.netlfdms-web-agency/ componentlsu bmitter InfoCover Page ?Call=. .. 8/26/201 0 
8/10/2010 

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 (Deductibles/OOP) 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 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: 

A "substantial change" to the provider network 

Consumers believe their provider and the provider network associated with any plan is an inte9ral 

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 shoJld 

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 consider€,d 

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 citizerls 

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. Anthony R. Galante 

2210 Huntingtin Dr. N 

Algonquin, I L. 60102 

847-854-2000