QUESTION

What is a grandfathered plan? How do I know if I have one?

Individuals with coverage | Individual and Marketplace Health Coverage
ANSWER

Grandfathered plans are those that were in existence on March 23, 2010 and have stayed basically the same in terms of benefits and cost-sharing. If you buy coverage on your own and you first purchased your policy prior to March 23, 2010, it may be a grandfathered plan. If you first purchased the policy after that date, it is not grandfathered. If your non-grandfathered policy came up for renewal in 2014, it would have had to change to follow all the new rules required of other health plans. However, some non-grandfathered plans renewed late in 2013 in order to avoid complying with the Affordable Care Act’s protections, so check your renewal date if you’re not sure. If you currently are covered under a non-group policy – whether it is grandfathered or not –, you can also explore other qualified plans offered through the marketplace and, if you prefer, you can switch to one of the new plans during open enrollment. To be eligible for a tax credit to help pay your premium – which will be based on your income – you must enroll in a plan offered through the marketplace.

Some group plans offered by employers may also be grandfathered plans. A grandfathered group plan also must have been first established prior to March 23, 2010. To retain grandfather status, the group plan cannot be significantly changed (that is, the employer can’t significantly change covered benefits or cost-sharing, or the share of the plan premium that you are required to contribute). Meanwhile, however, grandfathered plans are not required to provide all of the benefits and consumer protections required of other health plans. For example, a grandfathered health plan might not cover preventive health services. Employers with grandfathered group health plans are allowed to enroll new employees in the grandfathered plan. So even if you first joined a group health plan after March 23, 2010, you should ask about its grandfathered status. Your employer or your insurer must let you know if your health plan is grandfathered.

Your employer may also have renewed its group health plan late in the fourth quarter of 2013 in order to avoid complying with the full range of Affordable Care Act consumer protections, which went into effect on January 1, 2014. If you wish to know whether your employer-based coverage meets the requirements under the Affordable Care Act, check with your human resources department. (45 C.F.R. 147.140).

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