August 11, 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-9991-IFC 

 

 

Dear Mr. Mayhew: 

The undersigned organizations representing child health advocates, pediatricians, 

hospitals and other health providers congratulate you on the promulgation of successive 

regulations to implement the reforms established in the Affordable Care Act (PL 111-148 

as modified by PL 111-152). In particular, we congratulate the Departments of Treasury, 

Health and Human Services and Labor (the Departments) on striking a balance between 

continuity of coverage and enhanced consumer protection in promulgating the Interim 

Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as 

a Grandfathered Health Plan Under the Patient Protection and Affordable Care Act (the 

“Regulation” [found at 75 Fed Reg 34538-34570]). Nevertheless, we urge you to 

consider modifying the Regulation so that any negative impact on children can be 

ameliorated. 

We focus on the needs of children in this comment in four areas: the need for every child 

to have access to clinically appropriate preventive care and for families to work with the 

pediatrician of their choice, the need to protect children and youth with special health 

care needs (CYSHCN) through the Regulation, whether changes in plan structure and 

provider networks or family coverage should create a loss of grandfather status, and what 

enforcement and monitoring mechanisms should be in place to meet the full potential of 

these reforms for children. In each case, we recognize the balancing that the Departments 

undertook, but would urge that these decisions be re-examined to benefit children, and 

that diminutions in coverage lead to a loss of grandfather status. 

Every child needs preventive services, which are the hallmark of pediatric care. We 

applaud the promulgation of the Interim Final Regulation at 75 Fed Reg 41726-41760 

which establishes that non-grandfathered plans are required to provide coverage for all 

Bright Futures services. We also fully support the Interim Final Regulations found at 75 

Fed Reg 37188-37241 which will make it easier for families to access the doctors of their 

choice. 
However, the implementation of the grandfather rule means that millions of children 

currently covered by private insurance will be denied the benefits offered by these new 

provisions, leaving many children without access to the full panoply of clinicallyappropriate services and the ability to choose a pediatrician. Children and youth with 

special health care needs live in one in five U.S. households and comprise 14% of all 

U.S. children. We are especially concerned about these protections not being applied to 

these high risk children and youth. While it is laudable to ensure that families can 

continue insurance coverage for their children by keeping the growth in their insurance 

cost low, covering prevention for children, including those with special needs, is 

comparatively inexpensive. Indeed, many employers have discovered the value of 

prevention and see the need to support services like the immunization system in the 

United States that clearly have a strong return on investment in human and economic 

terms. 

Thus, we would urge the Departments to implement tighter restrictions on what changes a 

plan can make before it loses grandfather status so that more children will be further 

protected from decreases in the quality or affordability of their existing coverage under 

the Regulation. At a minimum, we also recommend that the following changes trigger a 

loss in grandfather status: 

o Restrictive changes to family coverage, including dropping coverage for a spouse 

or child or increasing costs beyond the limits outlined in the interim final rule. 

o Negative changes in prescription drug formularies that would adversely affect 

beneficiaries, including removal of a drug from the formulary that is medically 

necessary for treatment of a child's condition, the addition of prior authorization 

or quantity limits, and/or moving a drug to a higher cost sharing tier. 

o Changes in plan structure that would negatively alter coverage arrangements, 

including a switch from an insured to a self-insured product, which could severely 

impact coverage for CYSHCN. 

o Changes to a provider network of primary care clinicians and subspecialists that 

would adversely affect access to care. In many instances, CYSHCN may receive 

services from a limited panel of subspecialty clinicians and thus, a reduction in 

this panel could be financially devastating to a family that may live in a rural or 

other area that lacks a sufficient provider base for specialty care. 

In addition, we respectfully request that the Regulation provide for continuity of 

providers in the event a plan loses its grandfathered status. We are concerned that, in the 

absence of such a requirement, a plan may alter its panel of providers as a result of losing 

its grandfathered status. 

Finally, we ask that you give strong consideration to the enforcement of the grandfather 

provisions. The notice to families outlined in the interim final rule is a good first step, but 

it relies heavily on individuals to monitor the practices of their employers and insurers. 

We encourage the Departments to work closely with states to develop monitoring and 

enforcement mechanisms to verify effective implementation of the grandfather rules. 
Thank you very much for your attention to the views of our organizations and the needs 

of children in your consideration of the Regulation. 

Sincerely, 

Academic Pediatric Association 

American Academy of Pediatrics 

American Pediatric Society 

American Thoracic Society 

Association of Maternal and Child Health Programs 

Association of Medical School Pediatric Department Chairs 

Beckett Family Consulting 

Child Welfare League of America 

Children’s Defense Fund 

Children’s Dental Health Project 

Children’s Health Fund 

The Children’s Partnership 

Easter Seals 

Families USA 

Family Voices 

First Focus 

Georgetown Center for Children and Families 

March of Dimes 

The National Alliance to Advance Adolescent Health 

National Association of Children’s Hospitals 

Society for Adolescent Health and Medicine 

Society for Pediatric Research 

Voices for America’s Children 

ZERO TO THREE