Frequently Asked Questions

What provisions are grandfathered plans exempt from following?

• No cost-sharing requirements for preventive care
• Nondiscrimination testing of insured plans
• Establishing a pediatrician as a Primary Care Physician
• No referrals for OB/GYN services

What provisions are grandfathered plans required to follow?

• No lifetime or annual dollar limits on coverage of essential benefits
• No rescission of coverage except in cases of fraud or intentional misrepresentation of material fact
• Extension of parents' coverage to young adults under 26 years old
• No coverage exclusions for children under 19 with pre-existing conditions

What is the benefit of grandfathering my plan?

• Avoid the cost of preventive benefits
• Avoid some Health and Human Services Reporting requirements
• Can maintain a discriminatory insured plan (a richer plan design for the owner of the organization or highly paid employees than available for other employees)

What would cause loss of grandfathered status?

• Change in insurance carrier, policy, certificate or contract
• Elimination of all benefits to diagnose or treat a particular condition (i.e. removing self-injectable drugs)
• Increase in coinsurance
• Increase in deductibles or copayments subject to the applicable cost-adjustment test
• Change in funding status from self-funded to fully insured
• Decrease in employer contribution of more than 5%