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August 11, 2010

VIA ELECTRONIC MAIL

Office of Health Plan Standards and Compliance Assistance
Employee Benefits Security Administration, Room N-5653
U.S. Department of Labor

200 Constitution Avenue, NW

Washington, DC 20210

Attn: RIN 1210-AB41

Re: — RIN 1210-AB41; OCIIO-4150-IFC

Interim Final Rules for Group Health Plans and Health Insurance
Coverage Issuers Relating to Dependent Coverage of Children to Age
26 Under the Patient Protection and Affordable Care Act

Dear Sir or Madam:

We submit this response to the request for comments on the interim final
regulations relating to dependent coverage of children to age 26 under provisions of
the Patient Protection and Affordable Care Act (“PPAACA”). The request was
published by the Internal Revenue Service, Department of the Treasury; the
Employee Benefits Security Administration, Department of Labor; and the Office of
the Secretary, Department of Health and Human Services (the “Departments”) in the
Federal Register, Vol. 75, No. 92, on May 13, 2010.

Section 2714 of the Public Health Service Act, as added by the PPAACA and
as amended by the Health Care and Education Reconciliation Act, and the interim
final regulations provide that a plan or issuer that makes available dependent
coverage of children must make such coverage available for children until attainment
of 26 years of age. The statute also requires the issuance of regulations to define the
dependents to which coverage shall be made available under this rule.

T 803.540.2018
F 803.727.1487

E sgodom@nexsenpruet.com

Nexsen Pruet, LLC

Attorneys and Counselors at Law

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Comment to Interim Final Regulations
August 11, 2010
Page 2

The interim final regulations require uniformity of dependent coverage
irrespective of age and provide that the terms of the plan or policy for dependent
coverage cannot vary based on the age of a child, except for children age 26 or older
(the “Uniformity Requirement”). The examples to the interim final regulations
illustrate that where dependent coverage is provided for children under age 26,
premium surcharges for children over age 18 but under age 26 would violate the
Uniformity Requirement.

The interim final regulations also illustrate that where a group health plan
offers two benefit packages and dependent coverage is provided for children under
age 26, the plan would vary the terms of dependent coverage of children based on age
if the plan limits children who are older than age 18 to only one of the two benefit
packages.

However, the interim final regulations provide that a plan would not violate
the Uniformity Requirement if the cost of coverage increases based on the number of
individuals covered under various tiers of health coverage (e.g., self-only, self-plus-
one, self-plus-two, or self-plus-three-or-more) offered under the plan because the cost
of coverage increases would apply without regard to the age of any child.

In response to the interim final regulations, the following request for
clarification is submitted regarding changes to plan administration:

1. Age-Appropriate Variations of Terms of Coverage for Dependent
Children

Plans often impose age-based limitations on dependent coverage that are
designed to provide benefits to those age groups for which the coverage is age-
appropriate. For example, group health plans often provide benefits for children
under the age 3 for or in connection with well-baby care, including physical
examinations, development assessments, anticipatory guidance and appropriate
immunizations and laboratory tests, but do not provide the same coverage for these
benefits for dependent children age 3 and older. The Uniformity Requirement
appears to suggest that a group health plan would be required to extend coverage or
benefits specifically intended for babies or children in early developmental stages to
all children under 26.

2. Age-Appropriate Variations of Terms of Coverage for All Covered
Persons

Moreover, plans also impose age-based limitations that apply to both covered
employees and their eligible dependents (i.e., plan-wide limitations), which again are
designed to provide benefits to those age groups for which the coverage is age-
appropriate. For example, some plans providing both medical and dental coverage
limit orthodontia benefits for both covered employees and their eligible dependents to

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Comment to Interim Final Regulations
August 11, 2010
Page 3

individuals who are age 19 or younger. Moreover, some plans restrict Papanicolaou
("Pap") laboratory screening tests and prostate specific antigen ("PSA") testing only
to covered persons who are over the age of 3.

Clarification is requested regarding the application of the Uniformity
Requirement. A strict reading of the Uniformity Requirement would suggest that
these age-appropriate coverage restrictions, whether applicable only to dependents or
plan-wide, are not permitted. We believe that such an interpretation is not the
intended result of the PPAACA or its implementing regulations. Instead, we believe
the better interpretation or application of the interim final regulations is that plan-
wide or other age-appropriate restrictions or limitations on coverage do not violate the
Uniformity Requirement.

We appreciate this opportunity to provide the foregoing comments regarding
the interim final regulations. Should you have any questions, please do not hesitate to
contact me by phone at (803) 540-2018 or by email at sgodom@nexsenpruet.com.

Very truly yours,
NEXSEN PRUET, LLC

e G. Odom, Esq.,
lember

SGO/BBM

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