nea

1201 16thSt.,N.W. I Washington, DC20036 | Phone:(202)833-4000 Dennis Van Roekel

President

Lily Eskelsen

Great Public Schools y(ce President

for Every Student

Rebecca S. Pringle

Secretary-Treasurer

August 27,2010

John I. Wilson

Executive Director

Office ofConsumer Information and Insurance Oversight

Department ofHealth and Human Services

P.O. Box 8016

Baltimore, MD 21244-1850

Attention: OCIIO-9994-IFC

Comments on CFR 75 27171 submitted electronically at http://www.regulations.gov

Ladies and Gentlemen:

On behalf ofthe 3.2 million members ofthe National Education Association, I am pleased to

provide comments on the Final Rule and Proposed Rule for Group Health Plans and Health

Insurance Issuers Relating to Preexisting Condition Exclusions, Lifetime and Annual Limits,

Rescissions, and Patient Protections, 75 Fed Reg. 37188-37241, (June 28,2010).

NEA has long supported health care reform efforts that would provide access to affordable and

comprehensive health care coverage for all Americans while, at the same time, working towards

improving the U.S. health care system. NEA greatly values and appreciates the hard work ofthe

Departments ofthe Treasury, Labor, and, Health and Human Services in drafting and finalizing

these and other regulations related to the new health care law.

The following are the NEA's comments on 75 Fed Reg. 37188-37241, Part 147—Health

Insurance Reform Requirements for the Group and Individual Health Insurance Markets:

§ 147.126, No lifetime or annual limits,

1) In-network and out-of-network services. The interim final rule (IFR) does not specify

whether the "No lifetime or annual limits" provision applies to both in- and out-of-network

services. Given the way health plans function in practice, NEA believes that the "no lifetime or

annual limit" provisions should apply to covered health care services provided by both innetwork and out-of-network providers.

In many situations, patients need to use out-of-network facilities or providers. Health benefit

plans and policies often negotiate favorable reimbursement rates with providers who agree to

participate in a network in exchange for, among other things, a guarantee of patients with health

insurance and prompt reimbursement of claims. Many physicians and hospitals, however, do not

participate in provider networks.
August 27,2010

Office ofConsumer Information and Insurance Oversight

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Entire specialty groups are oftenmissing from network panels (e.g., manypediatric specialists,

neurosurgeons, and anesthesiologists areoften absent from networks). As a result, patients who

needcertain typesofspecialty caremustsometimes use an out-of-network provider.

In addition, evenwhena patientreceives services from an in-network hospitalor outpatient

facility, non-network providers often provide some of the careand laterbill the patient at the

non-network rate. In the case of emergency or urgent care, the patient may not have had the

abilityat the time ofservice to determine if a facility or provider was in their network.

Furthermore, many in-network primary care physicianshave stopped accepting new patients on a

short-or long-term basis, forcing the patientto seek care out-of-network. In these situationsthe

patientis usually left with exorbitantout-of-pocket costs. Patients should not be financially

penalized even further with lifetime or annual limits.

2) Benefit-specific lifetime limits. The IFR does not specify ifit would be permissible for

plans/policies to establish benefit-specific lifetime limits. NEA believes that lifetime benefitspecific limits for essential benefits should be prohibited for all health plans and policies.

Many plans limit the number ofinpatient hospital days allowed or the number of certain

outpatient treatments available over the course of an enrollee's lifetime. Lifetime treatment

limits fail to address the particular health needs ofpatients for whom such a limit could be

devastating or, worse, fatal (e.g., a one organ transplant lifetime limit). Further, a benefit plan

could, in theory, completely undermine the goals ofthe health care reform law by replacing an

overall lifetime limit with a series ofbenefit-specific lifetime limits. Benefit-specific limits

would also discriminate against the sick, causing irreparable damage to the sickest ofpatients

and undermining the purpose ofthis reform provision.

3) One overall annual limit. The IFR does not specify if a plan/policy would be permitted to

establish only one overall annual limit during the restricted annual limit period or if a plan/policy

could establish separate limits on a benefit-specific basis that would then add up to the total

allowed restricted annual limit. Many plans/policies have already indicated that they plan to

establish limits on a benefit-specific basis, during this time period, for high-cost benefits.

NEA believes that plans/policies should include at most one overall annual limit and not be

permitted to break out the limit on a per-benefit basis during the restricted annual limit period.

We believe that this practice penalizes patients who need certain essential services, discriminates

against the sickest patients, and undermines the purpose ofthis reform provision.

4) Waiver from annual limits. The IFR indicates that group health plans/policies may receive a

waiver from the restricted annual limits prior to 2014 if compliance would result in a significant

decrease in access to benefits under the plan/policy or would significantly increase premiums for

the plan or health insurance coverage.

NEA requests the establishment ofparameters that will be utilized to measure what a

"significant" decrease in access and/or increase in premium would be for purposes ofreceiving a

waiver so that consumers and plan stakeholders can review and provide comments.
August 27,2010

Office ofConsumer Information and InsuranceOversight

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§ 147.38 Patient Protections.

5)Coverage of emergency services. The lawrequires that plans/policies cover emergency

services without prior authorization and regardless ofwhether they are provided in- orout-ofnetwork. The IFRrefers to "benefits with respect to services in an emergency department of a

hospital." Please clarify whetherthe rule also applies to emergency care provided aturgent care

centers, in an air, land or water ambulance, and other settings.

NEA believes that the prior authorization for emergency services should apply to settings and

providers otherthanjust the "emergency department of ahospital." For example,otherapproved

emergency settings, modes of emergency response, andemergency transportation shouldalsobe

included. People living in many parts oftheUnited States do not live neara hospital. Also,

people in remote areas ofthe country in need of emergency care must depend onwhatever

emergency response team is available, whether ornotservices are provided in a hospital setting.

Thank you again for all the hardwork and for clarifyingthe issues that have come up forNEA

members and their health plans. We anxiously await your responses to these comments.

purstnilyO

aabc, Director

Collective Bargaining & Member Advocacy

National Education Association

1201 16th St., NW

Washington, DC 20036