, <, 

Tennessee 

Chiropractic 

Association 

August 11,2010 

Office of Consumer Information and Insurance Oversight 

Department ofHealth 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 PPACA. 

To Whom It May Concern: 

Please review the following 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). 

Our association represents Tennessee chiropractors and their staff and we believe the "Grandfathering 

rule" is likely to alienate numerous individuals from being covered by PPACA. 'It is imperative for 

healthcare consumers to partake and be covered by PPACA by January of2014 when many of the laws 

particulars come to fruition, such as tax credits, subsidies, and insurance exchanges. 

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 

• Elimination of substantially all benefits to treat a particular condition 

• Elimination ofbenefits 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) 

On the surface, the above bullet points are to the point; however there still appears to be much room for 

interpretation. Take for instance, an employer who altered a percentage/copayment in one aspect of the 

policy, yet retained the same percentage/copayment level for family doctor visits, would grandfather 

status be revoked or could this be a way of getting around the triggers as listed above? Specificity will be 

vital for large companies and small businesses, as well as their employees. 

Healthcare consumers often have a nebulous understanding of policy terms. As you know, an individual's 

health care is important and their needs to maintain a satisfactory quality of life often go beyond the 

fundamentals of covered benefits, cost sharing and the various contribution levels associated with • 

insurance policies. There are other aspects of health care services that will have a considerable impact on 

the small or large business employee that can result in an alteration oftheir plan including: 

2123 8th Avenue South, Nashville, TN 37204 (615) 383-6231 fax (615) 383-6233 web: tnchiro.com 
• 	 A "substantial change" to the provider network 

Consumers believe their provider and the provider network associated with any plan is an integral -p 

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 shollld 

be viewed as a substantial change to the plan itself. As a guideline, we wettld suggest any change 

in the provider network impacting over 50% ofthe employee population (nationally or locally) 

should result in a loss of the grandfather status. 

• 	 . Change in issuer or third-party administrator (TPA) (including movingftomfully-insuredto 

self-funded) 

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

-~ ·-~·admiiiistrat1oii ()flfie planrequn.es new ooriiiilunication, newproeesses, ·and new require~etitsOn ~ 

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 oftheir • 

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. 

In many estimates, there are large portions of large and small business employees that will not be able to 

participate in PPACA as ofJanuary 2014 based on the current guidelines and rules. We understand the 

monumental task ofthe implementation ofthis law, but our doctors in the chiropractic community are 

concerned that their patients may be part of a large sub-population to be excluded from the healthcare 

reform law. Patients will be confused, costs will rise and the potential positive impact ofthe legislation 

may be dampened ifthis is allowed to occur. The CBO has already projected a budget deficit since the 

inception ofthe process and we believe consumers who are excluded will only add to the deficit. .......... -.- -...... ~ .. .--c.......;.s:- -.-~"'~"~ -",-~",._~ _.-.; ~_...;... .--- __ _. _ ,,;e _' ____- - _ 


We ask that any changes related to the areas listed above shall 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 without ambiguity being involved in determining whether a group health plan is "in or 

out." Our collective decisions we make today will determine the outcomes for tomorrow. We will need 

to make 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. 

Sincerely, 

~ Jh{~ Cole Rosenfeld, DC, CCSP 	 Tiffany Stevens 

President 	 Executive Director