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.ur' ') r; Ii \J L J 

iJj¥~X~OCON·E~SING DIVISION 

8RAN~OULATIONS As of: August 26, 2010 

Received: August 10, 2010 

Status: Posted 

Posted: August 26, 2010 

Tracking No. 80b2dafO 

PUBLIC 

SUBMISSION Comments Due: August 16, 2010 

Submission Type: Web 

Docket: IRS-2010-oolO 

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-201o-oo1o-00o1 

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-2010-00lO-o452 

Comment on FR Doc # 2010-14488 

Submitter Information 

Name: Evana Younan 

Address: 

6837 N Lincoln AVe 

Lincolnwood, IL, 60712 

Email: eyounan@gmail.com 

Phone: 847-675-8305 

Fax: 8476758306 

Organization: Illinois chiropractic SOCiety 

Government Agency Type: State 

General Comment 

August 10, 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 

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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 


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 some confusion 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 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: 

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 sh·:>uld 

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 selffunded) 

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 

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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. 

Evana Younan D.C 

Lincolnwood Chiropractic Health Center 

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