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r;<EC-~1 J~4JJ-JO 

LEGAL PROCESSING DIVISION 

PUBLICATION & REGULATIONS 

BRANCH As of: August 26, 2010 

Received: August 10, 2010 

Status: Posted 

Posted: August 26, 2010 

Tracking No. 80b2db78 

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-0463 


Comment on FR Doc # 2010-14488 


Submitter Information 

Name: Raymond Salvatore Manasia 

Address: 


8 W Chestnut St 


Chicago, IL, 60610 


Email: drray_uhichicago@yahoo.com 


Organization: Universal Health Institute 


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General Comment 

Attachments 

IRS-2010-0010-0463.1: Comment on FR Doc # 2010-14488 

https:llfdms.erulemaking.netlfdms-web-agency1componentlsubmitterlnfoCoverPage?CalI=... 8/26/20 10 
August 10,2010 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Attention: OCII0-9991-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 (PP ACA). 

We believe that every effort should be made to increase the number of individuals 

covered by PPACA, especially as ofJanuary 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 ofmaintaining grandfather status 

Elimination ofsubstantially 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 copaymem 

level beyond the maximum in one area (Le. 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 h: an 

integral part ofthe 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 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 ofthe grandfath;:!r 

status. 

Change in issuer or third-party administrator (I'P A) (including moving from fullyinsured to self-funded) 

Even if the benefit structure of a group health plan remains largely the same, a change in 

administration ofthe plan requires new communication, new processes, and new 

requirements on the part of an employee and the employer. Moving from a fully-insur.;:d 

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 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 

mitigate the potential impact ofthe 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 

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. 

Raymond S Manasia DC 

Chiropractic Physician