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August 9, 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: IntetimFinal Rule for Group Health Plans and Health Insmance 

Coverage Relating to Status as a Grandfathered Health Plan Under the 

Patient Protection and Af10rdable Care Act . 

Below are om comments regarding the Interim Final Rule for Group 

Health Plans and Health Insmance 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 reforni components (Insmance 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 withthe sole intention of maintaining 

grandfather status 

Elimination ofsubstantially all benefits to treat a particular condition 

[;Jimination 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) 


Empl9yer contribution (> 5% reduction in Employer Contribution) 


71-31 Myrtle Avenue, Glendale, NY 11385-7223 - 800-426-6922 - Fax 718-497-0972 - NYCouncil@aol.com 
While relatively straightf~)rward; these guidelines may still result in 

some confusion to the marketplace in their application. For example, if 

an employer raised the co-payment level beyond the maximum in one 

area (i.e. outpatient services) but retained the co-payment 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 benet Its, 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 to their plan including: 

Consumers believe their provider and the provider net\vork associated 

with any plan is an integral part of the health care benefits provided by 

the employer. A termination o1'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 ofthe grandfather status. 

Change in issuer or third-party administrator (ITA) (including moving 

fi'01nfully-insured to ,<;(df1imded) 

Even ifthe 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 PaIt of an 

employee and the employer. Moving from a fully-insured to a selffunded status or changing administrators requires new processes and 

legal agreements fgT)he group~h9altb pla,n.J'heseJrat1;'3itions are not c 

daily or regular events aIld should be considered a change in the group 

health plan. 

S'ignificant change in care management/authorization requirements 

The processes consumers need to follow to receive care are a Significant 

component of their 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 

'ChaIlge to the plan. This may prevent group health piaI1S from 

maintaihing their grandfather status by not necessarily eliminating a 

benefit, but making it difficult to receive by changing the care 

management process around it. 

today will 

determine the outcomes for tomorrow. We may need to make some 

diJ'f:icult 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 coimtry participating at the beginning to make it work 

and delivering on its promises to retain their support. 

...."""'.v.1Vl,'v we 

or the opportunity to comment on this reguiation. 

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