What Does Having a "Grandfathered" plan mean under reform?

The Affordable Care Act exempts most plans that existed on March 23, 2010--the day the law was enacted--from some of the law’s consumer protections. This will preserve consumers’ rights to keep the coverage they already had before health reform.

What This Means for You

If you have health coverage from a plan that existed on March 23, 2010--and that has covered at least one person continuously from that day forward--your plan may be considered a “grandfathered” plan.

This is true whether you are covered by an individual health insurance policy that you had on that date, or you are covered by a job-based health plan that your employer first established before March 23, 2010. This is true even if you enrolled in that job-based plan sometime later.

A grandfathered health plan isn’t required to comply with some of the consumer protections of the Affordable Care Act that apply to other health plans that are not grandfathered.

Here’s a look at which consumer protections do and don’t apply to grandfathered plans.

Consumer Protections in the Affordable Care Act that DO Apply to Grandfathered Plans

Many of the Act’s consumer protections that took effect on September 23, 2010 apply to all plans, whether or not the plans are grandfathered.

Please note that these consumer protections will be added to your plan when it begins a new plan year orpolicy year on or after September 23, 2010.

All health plans:

• Are prohibited from applying lifetime dollar limits to key health benefits.
• Are not permitted to cancel your insurance coverage solely because of an honest mistake that you or your employer made on your insurance application.
• Must extend dependent coverage to an enrollee’s adult children until they turn 26 years old (with one temporary exception: Click here for more details).

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered Plans

Unlike other health plans, job-based plans and individual insurance policies that are grandfathered arenot required to:

• Provide certain recommended preventive services at no additional charge to you.
• Offer new protections for consumers who are appealing claims and coverage denials.
• Protect your choice of health care providers and your access to emergency care.

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered INDIVIDUAL Plans

Grandfathered individual health insurance policies are not required to adopt the provisions of the law that:

• Phase out annual dollar limits on key benefits.
• Eliminate pre-existing condition exclusions for children under 19 years old.

Some Important Details

Grandfathered plans can lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. (Read more about changes that will cause a health plan to lose grandfathered status).

Although grandfathered plans can make only limited changes to the percent of the premium the employer contributes, grandfathered plans may still increase their total premium amount without losing grandfathered status.

If your plan loses its grandfathered status, all of the Affordable Care Act consumer protections would apply to you when your plan begins a new plan year or policy year.

To find out if your health plan is grandfathered:

• Check your plan’s materials. Beginning with the first plan or policy year starting on or after September 23, 2010, health plans must disclose their grandfathered status in any plan materials describing the plan’s benefits that are distributed to beneficiaries or primary subscribers. These materials must also contain contact information for questions and complaints.
• Check with your employer and/or your health plan’s benefits administrator. If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to a grandfathered group plan after March 23, 2010.

For additional questions please contact the shoppe.

Thanks,

Jordan