AAP Headquarters 

141 Northwest Point Blvd 

Elk Grove Village, IL 60007-1098 

Phone: 847/434-4000 

Fax: 847/434-8000 

E-mail: kidsdocs@aap.org 

www.aap.org 

Reply to 

Department of Federal Affairs 

Homer Building, Suite 400 N 

601 13th St NW 

Washington, DC 20005 

Phone: 202/347-8600 

Fax: 202/393-6137 

E-mail: kids1st@aap.org 

Executive Committee 

President 

Judith S. Palfrey, MD, FAAP 

President-Elect 

O. Marion Burton, MD, FAAP 

Immediate Past President 

David T. Tayloe, Jr, MD, FAAP 

Executive Director/CEO 

Errol R. Alden, MD, FAAP 

Board of Directors 

District I 

Edward N. Bailey, MD, FAAP 

Salem, MA 

District II 

Henry A. Schaeffer, MD, FAAP 

Brooklyn, NY 

District III 

Sandra Gibson Hassink, MD, FAAP 

Wilmington, DE 

District IV 

Francis E. Rushton, Jr, MD, FAAP 

Beaufort, SC 

District V 

Marilyn J. Bull MD, FAAP 

Indianapolis, IN 

District VI 

Michael V. Severson, MD, FAAP 

Brainerd, MN 

District VII 

Kenneth E. Matthews, MD, FAAP 

College Station, TX 

District VIII 

Mary P. Brown, MD, FAAP 

Bend, OR 

District IX 

Myles B. Abbott, MD, FAAP 

Berkeley, CA 

District X 

John S. Curran, MD, FAAP 

Tampa, FL 

August 26, 2010 

Jim Mayhew 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Hubert H. Humphrey Building, Room 445-G 

200 Independence Avenue, SW. 

Washington, DC 20201 

Attention: OCIIO-9994-IFC 

Dear Mr. Mayhew: 

The American Academy of Pediatrics (AAP), a non-profit professional organization of 

60,000 primary care pediatricians, pediatric medical sub-specialists, and pediatric surgical 

specialists dedicated to the health, safety, and well-being of infants, children, adolescents, 

and young adults appreciates this opportunity to submit comments regarding the interim 

final rules for Patient Protection and Affordable Care Act: Preexisting Condition 

Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections (6 CFR Parts 

54 and 602, 29 CFR Part 2590, 45 CFR Parts 144,146, and 147). 

The Academy is very supportive of many aspects of this new regulation, especially the 

opportunity for more than half a million children to receive coverage through their parents 

insurance even though they have pre-existing conditions, but recommends changes to the 

regulations in regard to annual limits rules, the imposition of waiting periods for children 

with pre-existing conditions, and the definition of an appropriate pediatrician. 

Thank you very much for your attention to the views of the American Academy of 

Pediatrics. 

Sincerely, 

Judith S. Palfrey, MD, FAAP 

President 
Patient Protection and Affordable Care Act: Preexisting Condition Exclusions, Lifetime 

and Annual Limits, Rescissions, and Patient Protections (6 CFR Parts 54 and 602, 29 CFR 

Part 2590, 45 CFR Parts 144,146, and 147)

The Academy’s Access Principles call for all children to have access to quality health insurance 

as well as all recommended and needed services. The Affordable Care Act lays the groundwork 

to achieve this goal, with its focus on improving the nature of the health insurance available to 

individuals and families. Nevertheless, the Interim Final Rules for Preexisting Condition 

Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections (the Patients’ Bill 

of Rights) can be improved so that health insurance for children, and especially Children and 

Youth with Special Health Care Needs (CYSHCN), is strengthened. 

Overall, the Academy congratulates the Departments of Treasury, Labor and Health and Human 

Services (the Departments) on promulgating the Patients’ Bill of Rights after promulgating so 

many other impactful rules for the pediatric population. The rescissions section is particularly 

positive for children, both as regards to parents or other caregivers making attestations for 

children and a reasonable period for notice of a cancellation. Beyond the rescissions rules, the 

Patients’ Bill of Rights is clearly designed to strike a balance between cost and consumer 

protections. However, the Academy recommends changes in approach that will better meet the 

needs of children and their families. Program cost increases do not outweigh improving 

insurance coverage for the pediatric population. In particular, the Departments have missed the 

opportunity to enhance insurance for children by allowing insurers’ to impose long breaks 

between guaranteed issuance of insurance for children with pre-existing conditions, interpreting 

the annual and lifetime limits provisions exceedingly narrowly, and defining primary care 

provider to exclude pediatric specialty providers. 

Pre-Existing Conditions Exclusions. The Academy agrees with the Departments’ interpretation 

of the statute to apply to grandfathered plans. The Academy supports the policy put forth in the 

Patients’ Bill of Rights that prohibits not just an exclusion of coverage of specific benefits 

associated with a preexisting condition, but also prohibits a complete exclusion from a plan or 

coverage based on a preexisting condition. This policy will help make health insurance more 

accessible to CYSHCN who may have turned to Medicaid or CHIP as a result of being unable to 

find coverage in the private health insurance market. 

However, the Academy is concerned that the Departments did not address within the bounds of 

the Patients’ Bill of Rights that insurers may still impose waiting periods that can stretch for 

many months during a time when a family may have received a devastating diagnosis regarding 

their child’s health. A waiting period for coverage can be just as problematic as denial of 

coverage for a child who may need services promptly. The Academy urges the Departments to 

modify the Patients’ Bill of Rights to address this problem. 

Lifetime and Annual Limits. Section 2711 of the Affordable Care Act, which sets forth that 

annual and lifetime limits will no longer apply to many types of insurance, holds the promise to 

have great impact on children and families, and especially CYSHCN. During the health reform 

debate, the Academy was very pleased to learn that children with large annual health care costs 

covered by private insurance would have those caps lifted and that children with large lifetime 
health care costs offset by private insurance would not reach those limits early in their young 

lives. Unfortunately, the Patients’ Bill of Rights interprets this section of the Affordable Care 

Act in ways that will not meet the needs of many in this vulnerable population. 

Initially, the caps that the Patients’ Bill of Rights sets forth are too low for the sickest children,

and will clearly compromise their care. A child with cancer or multiple chronic conditions may 

easily utilize more than $750,000 in health services in one year. Additionally, it is doubtful why 

this number increases to $1.25 million in 2012, and $2 million before January, 2014. If a cap 

must be implemented, the Academy would urge the Departments to impose a much higher cap 

that does not arbitrarily change throughout the time before 2014. 

Next, the fact that the caps apply only to an as-yet undefined set of “Essential Benefits” is also 

troubling. All children should receive the medically necessary services that they need without 

caps, even if they are beyond the list of Essential Benefits listed in the new law. CYSHCN will 

derive the benefits of hospital coverage, coverage for rehabilitation and habilitation services and 

coverage for pediatric benefits, which are all listed as Essential Benefits in the Affordable Care 

Act. The Academy would urge the Departments to recognize the importance of these benefits to 

all children and thus, would urge that the Departments allow children be granted access to the 

medically necessary services they need under this rubric. Caps should not apply to medically 

necessary benefits in the pediatric population. 

Additionally, the use of a good faith standard regarding insurance companies that impose a cap is 

troubling. Because Essential Benefits are not defined, it appears that the Departments plan to 

grant insurers the option of deciding which benefits qualify, as long as those determinations are 

made in good faith. Granting insurance companies discretion over these life or death decisions 

for the sickest children is highly problematic because the goal of private insurers is to improve 

shareholder value, not to provide benefits to those insured. An insurers’ decision about which 

benefits are essential will likely not be made with the needs of insured children in mind, but 

instead has a great chance to be influenced by a need to increase shareholder value and medical 

loss ratios. 

Finally in regards to lifetime and annual limits, it is highly disappointing that sec. 54.9815-

2711T(d)(3) could effectively eviscerate this important component of the Affordable Care Act. 

This section of the Patients’ Bill of Rights establishes a poorly-defined program encouraging 

plans to apply for a waiver of the annual and lifetime limit rules. It appears that if plans are 

granted such a waiver, they may be able to avoid the imposition of the new annual and lifetime 

limits rules under the law. The need for such a program is highly questionable, and its impact on 

the lives of some of the sickest children and their families could be devastating. If such a 

program must be retained, the Academy would urge that the rules for it be highly transparent, 

with many opportunities for public input and that families of CYSHCN should be considered in 

every aspect of its establishment and implementation. 

Choice of Health Care Professional. The Academy has often stressed that children have health 

care needs that differ from those of adults, and as such the Academy is very pleased to see that 

the Patients’ Bill of Rights changes insurance to require plans that offer a provider panel to 

permit families to designate a pediatrician as a child’s primary care provider. However, for 
children with significant medical needs, a traditional pediatrician may not be the most 

appropriate designee. For example, a child with significant respiratory problems may see his 

pediatric pulmonologist more regularly than his general pediatrician, and his pediatric 

pulmonologist may in fact become the provider who regularly coordinates his care. In such a 

situation, the child’s family, in consultation with their clinicians, should be able to select as the 

primary care physician the provider who most often interacts with their child and whose 

expertise is most appropriate for the ongoing care that the child requires. The Academy suggests 

that the regulation be modified to clarify that in the instance of CYSHCN, plans allow a family 

to designate a pediatrician, pediatric sub-specialist, or other specialist handling the child’s care as 

the child’s primary care provider.