LEER CHIROPRACTIC CENTER, P.S.C. 

Ronald W Jeer, :Jj,c. 

212 S.MAIN ST., P.O. BOX 218 


LAOTTO, INDIANA 46763 


***** 


(260) 897-3001 

August 10,2010 

Office of Consumer lnfonnation and Insurance Oversight 

Department ofHealth and Human Services 

Attention: OCnO-999l-IFC 

P.O. Box 8016 

Ba1timore,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 

Belo}\' are our,comments regarding the Interim Final Rule for Group Health Plans and Health 

In~U,f~flf~,~?~n~~~,~~l~!ing to Status as a Grandfathered Health PI~ ~~d~r th~ Patient , " 

Protection and AffordaBle Care Act (PPACA). . , ,.. ..,'.. 

~.~. i~~··i . ~.~ ~j,"Jq ,,"V:)~ \"'-',\T~~·i:~}.f ~.: . 

We .b~l}~vt1 tn~~:~v~ry. e~fo}1.~hould pe l!l~de ~o i~~re~sethe num~er?r~R~~f~~a!~59.v~r7R ~~ .' 

ppA~A, .especlal~y, ':is :of Janpary 1, 2014 When most ofthe reform compon~nts Dn,surruwe ,. 

Exch8!.1g~s?S\ubsi~~e~<j~Ta,x·Credits; etc.) come intoplay. " " ~ ", r : 1:~":-: .~:;:~ ~.:; :';'. ' 

" :; . , 

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 


e Elimination of substantially all benefits to treat a particular condition 


• Eliminati'on of benefits for any element necessary to eliminate or diagnose a condition ",. .~, ~ .- ... ".- -- ~ , " ... 

e Any change to coinsurance level 

e Fixed-~mountcost;.shaiing (Deductioles'/OOP) Inflation +15% 

• Co~p~ymenls (Medical Inflation -+- 15% or $5 adjusted for medic{ll inflation),' .. , 

• ~mployer contribution (> 5% reduction in Employer Contribution) 

While relati~ely straightforward, these gUideAnes may s'tilltesult in son~e confusiort to the 

matkeml~ce iiflJ~eir appl~catjon. For exampl!,?, i(an:-employer raised the copayment level beyond 

the maximurilinonearea (i.e. outpatient serVices) hut 'retained the copayment level for primary "'" ... ... ~""' o',,!:'.'. ~ . lyl··'_'"'~~"'l. "', ';"t'::~~'"'' ,.., 

.c.are,q?c~<{r ,~i,sit~~ dp,~~ ~p~tlpean a loss <:fg~andfatheystatus? Clarity ~ll be priti~~r~?!~ for the 

employer and the employee. . ", ,. " ' '. "-'; 'j' 

The average consumer'has a broad definitionof"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: 
.... I /. 

D 	 A "substantial change" to the provider network 

Consumers believe their provider and the provider network associated with any plan is 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 500/0' of 

the employee population (nationally or locally) should result in a loss ofthe grandfather 

status. 

• 	 Change in issuer or third-party administrator (TPA) (including moving from fully­

insured to se?f: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. 

. • 	 Signtficant 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 :1 

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 of January 2014 based on the current rules. While we understand 

the difficulty involved in making changes, 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) whenthe 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 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 omment on this regulation. 

~~%If'~£)C Ronald W. Leer, D.C. . 


Indiana State Chiropractic Assoc Member