Although many healthcare reform requirements don’t begin until 2014, one component that’s been in place since 2010 is grandfathered and non-grandfathered health plan status.

It’s important you understand if your plan has grandfathered or non-grandfathered status because it affects the type of benefits you receive.

Grandfathered status plans are subject to some, but not all, portions of healthcare reform. If you have a grandfathered status plan, you may not have the same benefits as someone with a non-grandfathered status plan.

Overview of Grandfathered Status Plans

Grandfathered plans are health plans that were in place before March 23, 2010, when the Affordable Care Act was signed into law. These plans are allowed to offer the coverage they did before the Affordable Care Act. Changes can be made to grandfathered plans (subject to certain limitations) without losing grandfathered status. A grandfathered status plan might not include certain benefits or consumer protections that non-grandfathered plans are required to include. A few examples of this include:

  • Grandfathered status plans are not required to cover all preventive services at a $0 copay (such as contraceptive coverage).
  • Grandfathered status plans are not required to cover all of the benefits healthcare reform has deemed to be “essential,” such as certain types of testing and treatment.
  • Grandfathered status plans have different member appeal rights.

However, healthcare reform has added some benefits to both grandfathered and non-grandfathered status plans, including:

  • No lifetime dollar limit on benefits and/or no monetary limits on essential benefits (For example, your plan cannot have a $200,000 lifetime cap on organ transplants – it must be unlimited)
  • Dependent coverage to your adult children until they turn 26, subject to certain limitations (the age limit is 28 in Ohio for fully insured plans.)

Why Do Plans Have Grandfathered Status?

If you have individual coverage:
If you have individual health plan coverage with grandfathered status it’s because you have stayed in the same plan and/or not made a plan change affecting grandfathered status during your renewal.

If you have employer coverage:
When you have coverage through your employer, he or she makes decisions about what type of health coverage is available. Your employer also chooses whether your plan keeps its grandfathered status. As long as your employer maintains grandfathered status plans, your benefits will remain generally unchanged and your benefits may not be the same as someone in a non-grandfathered status plan. New plans created after March 23, 2010, will never have grandfathered status.

How to Determine if Your Plan Has Grandfathered or Non-Grandfathered Status

If you aren’t sure whether your plan is grandfathered or non-grandfathered, contact your broker or employer. If you are a Medical Mutual member and still have questions, call our Customer Care department at 800.242.1936.

Learn more about healthcare reform in our What Does Healthcare Reform Mean to Me? section.