Grandfathered & Non-Grandfathered Plans
Plans that have been active — and have basically stayed the same — since March 23, 2010, might have grandfathered status. As a reminder, grandfathered plans don't have to:
- Provide certain preventive care at no extra charge
- Offer a new, simpler way for appealing claims and coverage denials
- Let employees choose any participating primary care physician (PCP), pediatrician or emergency care
Non-grandfathered plans must cover preventive care (no copay, coinsurance or deductible) for some in-network doctor visits.
Losing Grandfathered Status
Remember that any changes you make, like lowering your coverage contribution rate by more than 5%, could cause your status to change.
For example, if you lower your employee-only contribution rate from 65% to 50%, you may lose your grandfathered status.
If your status changes, you may notice:
- Preventive care rules apply
- ER care — as well as out-of-network doctor visits — are covered without pre-approval
- A layperson meaning of an emergency health issue is used
- Workers can choose any participating PCP or pediatrician
- Women can see an OB/GYN doctor without pre-approval or referrals