Grandfathered Health Plans

Health plans that were in effect on 3 /23/2010 or earlier and that have only seen minimal or no changes to their coverage and costs are considered grandfathered plans. For a plan to preserve its grandfathered status, however, it must make a disclosure in its Summary of Benefits and Coverage, that notifies members of its status and provides contact information to the plan administrator, EBSA, or the Department of Health and Human Services, as applicable, for any questions or feedback. A model notice for the disclosure, with the contact information corresponding to each plan type, can be found here.

These plans do not meet the Affordable Care Act plan requirements but are not subject to the following reforms:

  • Fair health insurance premiums
  • Guaranteed availability of coverage
  • Guaranteed renewability of coverage
  • Nondiscrimination in health care
  • Comprehensive health insurance coverage
  • Coverage for individuals participating in approved clinical trials
  • Internal claims and appeals process, and external review
  • Coverage of preventive health
  • Provision of additional information
  • Prohibition on discrimination in favor of highly-compensated individuals
  • Ensuring quality of care
  • Patient protections

However, grandfathered health plans and all others are subject to the following ACA requirements:

  • No lifetime or annual limitations on coverage (Note: The prohibition on annual limits is not applicable to individual grandfathered health insurance coverage)
  • Prohibition of preexisting condition exclusion or other discrimination based on health status (Note: These provisions are not applicable to individual grandfathered health insurance coverage)
  • Prohibition on rescissions
  • Prohibiting discrimination against individual participants and beneficiaries based on health status (Note: HIPAA nondiscrimination provisions are not applicable to individual grandfathered health insurance coverage)
  • Prohibition on any waiting periods that exceed 90 days for group health plans and group health insurance coverage
  • No arbitrary cancellations of health coverage
  • Extension of coverage of dependent children up to the age of 26
  • Develop and use uniform explanation of coverage documents and standardized definitions
  • Medical loss ratio provisions (applicable to insured grandfathered plans)
  • All Applicable Large Employers are subject to Employer Shared Responsiblity provisions under the ACA, and 4980H of the IRS, effective Jan 1 2015.
  • All employers must submit an annual report to the IRS with information about the health benefits they offer, and the enrollment status of their employees. Learn more.
  • All plans must provide a Summary of Benefits and Coverage (SBC) document to participants and beneficiaries. The SBC must contain a brief and understandable summary of the plans, coverage, and costs.
  • Grandfathered plans must state on the Summary of Benefits and Coverage that they are grandfathered plans, and thus not subject to certain Affordable Care Act regulations. removed: (this SBC must be given to all employees annually with this declaration.)
  • The grandfathered status disclosure must be included in the plan's Summary of Benefits and Coverage, as well as any other communications in which the disclosure would be appropriate and consistent with the goal of providing participants and beneficiaries information necessary to make coverage decisions.

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