QUESTION

I heard not all plans have to meet all rules. How do I know if my plan has to comply?

Post enrollment issues | Employer-Sponsored Coverage
ANSWER

That’s right. Plans that were in existence on or before March 23, 2010 are known as “grandfathered” plans and don’t have to meet all the rules. Grandfathered plans are exempt from many of the Affordable Care Act rules for plans, including the requirement to cover preventive services without cost-sharing and to limit out-of-pocket costs. Your plan must tell you if it is grandfathered in any plan documents they send you. Over time, all plans will lose their grandfathered status and have to comply with rules that only apply to new plans. Note, however, that some rules don’t apply to self-insured and large employer plans, even if they are new (non-grandfathered).

It is also possible that your employer renewed your current plan in 2013, before it was required to come into compliance with most of the Affordable Care Act’s consumer protections. Referred to as transitional or “grandmothered” policies, most states allow small employers to keep these noncompliant policies if they were in effect on or before October 1, 2013 and do not extend past December 31, 2018, and also meet certain notice requirements. See FAQ 3.1.7 on “grandmothered” policies.

See Other Resources tab for more information on how the Affordable Care Act’s insurance rules apply to different plans. (45 C.F.R. § 147.200; 45 C.F.R. § 147.140; CMS, Insurance Standards Bulletin Series-Extension of Transitional Policy through Calendar Year 2018).

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