Congress ofChiropractic 


State Associations ... 

... promoting a more unifiedprofessiorz 

Office ofConsumer Information and Insurance Oversight 

Department ofHealth and Human Services 

Attention: OCII0-9991....,IFC .. , -.,., 

P.O. Box 8016 -­ Baltimore, MD 21244-1850 1 

t 

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 (PPACA). 	 . 

We believe that every effort should be made to increase the numbet ofindividuals covered 

by PPACA, especially as ofJanuary 1,2014 when most ofthe 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 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 sollleconfusion to the 

marketplace in their application. For example, if an employer raised the copayment level .. 

beyond the maXimum: in one area (Le. outpatient services) but retained the copayment level 

12531 E. Meadow Drive • Wichita, KS 67206 • Phone: 316.613.3386· Fax: 316.633.4455 


amy4hardin@yahoo.com 

for primary care doctor visits, does that mean a loss ofgrandfather 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 ofhealth care services can have a significant impact on the 

individual employee, which can result in a change t(}their plan: including: .. 

• 	 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 previdedby 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%· ofthe employee population (nationally or locally)shouldiesult 

_ jn a los~ Qf the ~~ather ~tatu~~ 

• 	 Change in issuer or third-party administrator (TP A) (including moving from folly­

insured toself-funded) 


Even ifthe benefit structure ofa group health plan remains largely the same, a 

change in administration ofthe plan requires new communication, new processes, 

and new requirements on the part ofan employee and the employer. Moving from a 

fully-insured to· a self-fonded, 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 

oftheir 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 --aroOOd it.' - .....- ~ ........-"- - ~. ~ - - w'.__ 


Even by the most optimistic estimates, a substantial portion ofthe employee population will 

remain outside the PPACA as ofJanuary 2014 based onthe cmrent 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 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 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 detennining 

12531 E. Meadow Drive • Wichita, KS 67206 • Phone: 316.613.3386· Fax: 316.633.4455 


amy4hardin@yah()();com 

•. 


whether a group health plan is "in or out." The decisions we make today will detennine the 

outcomes for tomorrow. We may need to make some difficult decisions IDcreate 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 00 its promises to·retain their support. 

m.H1l.fV to comment on this regulation . 

• ~Il»l;"Fed 0, DC 


1 nt Coogress of Chirepracti£ State Associations 


12531 E. Meadow Drive • Wichita, KS 67206 • Phone: 316.613.3386 • Fax: 316.633.4455 

amy4hardin@yahoo.com 

1