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AUG 2 7 2.010 

/LEGAL PROCESSING DIVISION 

PUBLICATION & REGULATIONS 

BRANCH 

As of: August 27, 2010 

Received: August 26, 2010 

Status: Posted 

Posted: August 27, 2010 

Tracking No. 80b3bfab 

PUBLIC 

SUBMISSION Comments Due: September 27, 2010 

Submission Type: Web 

Docket: IRS~2010~0015 

Requirements for Group Health Plans and Health Insurance Issuers under the Patient Protection 

and Affordable Care Act 

Comment On: IRS-2010-0015-0001 

Requirements for Group Health Plans and Health Insurance Issuers under the Patient Protection 

and Affordable Care Act: 

Document: IRS-2010-0015-0017 

Comment on FR Doc # 2010-15277 

Submitter Information 

Name: John Vincent Drucker 

Address: 

460 Summit Avenue 

Mill VAlley, CA, 94941 


Email: jvdrucker@yahoo.com 


Phone: 415-378-9131 


General Comment 

Re: Comment on 45 CFR 147.138(b) 

Suggested change: 

Add a section to 45 CFR 147.138(b) that requires a non-grandfathered plan to notify the 

beneficiary (via a reason code for each emergency service line on the explanation of benefits it 

provides the beneficiary) and medical professional and/or hospitals (via a reason code for ea:::h 

emergency service line on the reimbursement advise it provides a ER professionals and/or 

hospitals) that­

(a) the plan is a non-grandfathered plan and has determined its payment obligation for this 

covered emergency services line-item pursuant to the provisions 45 CFR 147.138(b)(3); 

or 

(c) ) the plan is a non-grandfathered plan and the plan has determined that the emergency 

services billed under this line-charge are not covered pursuant to the definitions in 45 CFR 

147.138(b)(4). 

Discussion: 

There is nothing in existing regulations, as far as I can determine, that requires a plan to inform a 

beneficiary or a provider (physician and/or facility) if the out-of-network payment rules of 45 CFR 

147.138(b(3» apply to each line-item that has been billed for out~of~network emergency 

https:llfdms.erulemaking.netlfdms-web-agency/componentlsubmitterinfoCoverPage?Call=... 8/27/2010 
Page 2 of2 

services. Absent this information neither beneficiaries nor providers will be able to easily fla~1 

questionable line-item payments by non-grandfathered plans for emergency services. 

ThiS undercuts the consumer protections in the proposed regulations (29 CFR Part 2590) which 

provide beneficiaries and providers with access to a streamlined dispute resolution process should 

they wish to dispute: 

(i) a non-grandfathered plan's determination that the services rendered do not meet certain 

medical necessity criteria (e.g.: the definition of covered emergency services in 45 CFR 147.138 

(b)(4); 

and/or 

(ii) Oi) that the amount being paid by non-grandfathered plan does not comply with the plan's 

out-of-network payment obligations pursuant to federal regulations (45 CFR 147 .138(b )(3) ). 

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Attachments 

IRS-2010-0015-0017.1: Comment on FR Doc # 2010-15277 

https:/lfdms.erulemaking.net!fdms-web-agency/ component! submitterInfoCoverPage?Call=... 8/27/2010 
Vincent Drucker 


460 Summit Avenue, Mill Valley, CA 94941 


415-378-9131 jvdrucker@yahoo.com 


Re: Comment on 45 CFR 147.138(b)(3) -- (Patient Protection Regulations pertaining to requiring nongrandfathered plans to reimburse appropriately for out-of-network emergency charges) 

Suggested change: 

Add a section to 45 CFR 147 .1 38(b) that requires a non-grandfathered plan to notify the beneficiary (via a 

reason code for each emergency service line on the explanation ofbenefits it provides the benefidary) 

and medical professional and/or hospitals (via a reason code for each emergency service line on the 

reimbursement advise it provides a ER professionals and/or hospitals) that­

(a) the plan is a non-grandfathered plan and has determined its payment obligation for this 

covered emergency services line-item pursuant to the provisions 45 CFR 147.138(b}:3); 

or 

(c) ) the plan is a non-grandfathered plan and the plan has determined that the emergency services 

billed under this line-charge are not covered pursuant to the definitions in 45 CFR 147.1 38(b)(4). 

Discussion: 

There is nothing in existing regulations, as far as I can determine, that requires a plan to inform a 

beneficiary or a provider (physician and/or facility) if the out-of-network payment rules of 45 CFR 

147.138(b) apply to each line-item that has been billed for out-of-network emergency services. Absent 

this information neither beneficiaries nor providers will be able to easily flag questionable line-itl~m 

payments by plans for out-of-network emergency services by non-grandfathered plans. 

This undercuts the consumer protections in the proposed regulations (29 CFR Part 2590) which provide 

beneficiaries and providers with access to a streamlined dispute resolution process should they wish to 

dispute: 

(i) a non-grandfathered plan's determination that the services rendered do not meet certain medical 

necessity criteria (such as the definition of covered emergency services in 45 CFR 147.138(b)(4); 

and/or 

(ii) 	 that the amount being paid by non-grandfathered plan does not comply with the plan's out-ofnetwork payment obligations pursuant to federal regulations (45 CFR I 47. 138(b)(3) ). 

Please contact me if you require additional details on any of the points I have raised. 

Respectfully submitted 

J Vincent Drucker 

Disclosure of Potential Conflicts of Interest 

I have no current source of revenue from any of the suggestions submitted above, as I am retired. My 

spouse has no sources of revenue from any ofthe suggestions submitted above. My spouse and I have no 

contracts that would allow us to have, in the future, any revenues from any ofthe suggestions submitted 

above. I have no children under 18 years of age or partners that would have any revenues from any ofthe 

suggestions submitted above.