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a REG-lIP412-/0

LEGAL PROCESSING
PUBLICATION & REGUL ARN
LAI
BRANCH “TIONS

As of: September 02, 2010

PUBLIC Status Posted

Posted: September 02 2010
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-2010-0010-0001
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-2010-0010-0609
Comment on FR Doc # 2010-14488

Rober Cashin . .
Graston Pom Ly Submitter Information

Chive prechie

General Comment

See attached file(s)

Attachments

IRS-2010-0010-0609.1: Comment on FR Doc # 2010-14488

https://fdms.erulemaking.net/fdms-web-agency/component/submitterInfoCoverPage?Call=P... 9/2/2010


August 11, 2010

Office of Consumer Information and Insurance Oversight
Department of Health and Human Services

Attention: OCIIO-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 (PPACA).

We believe that every effort should be made to increase the number of individuals covered by PPACA,
especially as of January 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 of maintaining grandfather status

e Elimination of substantially all benefits to treat a particular condition

¢ Elimination of benefits for any element necessary to eliminate or diagnose a condition
e Any change to coinsurance level

e Fixed-amount cost-sharing (Deductibles/OOP) Inflation +15%

e Co-payments (Medical Inflation +15% or $5 adjusted for medical inflation)

e 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 copayment level beyond the maximum in one area (i.e.
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:

e A “substantial change” to the provider network

Consumers believe their provider and the provider network associated with any plan is an integral part
of the 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 of
the grandfather status.

© Change in issuer or third-party administrator (TPA) (including moving from fully-insured to self-
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.

© Significant 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 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 of the employee population will remain outside the
PPACA as of January 2014 based on the current rules. While we understand the difficulty involved in making
change, 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) 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 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.

Robert W. Gaston, D.C.
Gaston Family Chiropractic
625 2" St

Traverse City, MI 49684
Tel: 231-922-5060