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

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