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%