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AUG 2 6 20'10 

LEGAL PROCESSING DIVISION 

PUBLICATION & REGULATIONS 

BRANCH 

As of: August 26, 2010 

Received: August 10, 2010 

Status: Posted 

Posted: August 26, 2010 

Tracking No. 80b2daaa 

PUBLIC 

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-2010-001O-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-0441 


Comment on FR Doc # 2010-14488 


Submitter Information 

Name: Joseph William Betz 


Address: 


3040 N. Five Mile Rd 


Ste C 


BOise, ID, 83713 


Email: drjoebetz@gmail.com 


Phone: 208-321-8484 


Fax: 2083215084 


Organization: Idaho Association of Chiropractic Physicians 


General Comment 

see attached 

Attachments 

IRS-2010-0010-0441.1: Comment on FR Doc # 2010-14488 

https:llfdms.erulemaking.net/fdms-web-agency1component/submitter InfoCoverPage?Call=... 8/26/2010 
Idaho Association of Chiropractic Physicians 

13601 W. McMillan Rd, Ste 102-331 

Boise, Idaho 83713 

www.idchiro.org 

info@idchiro.org 

Fax 888.399.5459 

August 6, 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 HeCllth 

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 covenad 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. 
Idaho Association of Chiropractic Physicians 

13601 W. McMillan Rd, Ste 102-331 

Boise, Idaho 83713 

www.idchiro.org 

info@idchiro.org 

Fax 888.399.5459 

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" ta 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 terminatkm of a 

hospital system or specific provider group sometimes has significant impact on thl:! 

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-in;;ured 

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 fullyinsured 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. 
Idaho Association of Chiropractic Physicians 

13601 W. McMillan Rd, Ste 102-331 

Boise, Idaho 83713 

www.idchiro.org 

info@idchiro.org 

Fax 888.399.5459 

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 sust4~inable 

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. 

Jon R. Gray, DC 

President, Idaho Association of Chiropractic Physicians