Grandfathered plans are not required to meet these PPACA requirements:

  • Modified community rating (starting with the 2014 plan year; this only applies to insured small group plans)
  • Coverage of preventive care without employee cost-sharing, including contraception for women
  • Expanded claims and appeal requirements
  • Limitations on out-of-pocket maximums (starting with the 2014 plan year)
  • Essential health benefits and metal levels (starting with the 2014 plan year; these only apply to insured small group plans)
  • Coverage of routine costs associated with clinical trials (starting with the 2014 plan year)
  • Guaranteed issue and renewal (starting with the 2014 plan year; this only applies to insured plans)
  • Nondiscrimination rules for fully insured plans (this requirement has been delayed indefinitely)
  • Additional patient protections (right to choose a primary care provider designation, OB/GYN access without a referral, and coverage for out-of-network emergency department services)
  • Reporting to HHS on quality of care (requirement has been delayed indefinitely)

These PPACA requirements apply to grandfathered plan:

  • PCORI Fee
  • Transitional Reinsurance Fee
  • Notice regarding the exchanges
  • Limits on eligibility waiting periods (starting with the 2014 plan year)
  • Dependent child coverage to age 26 (an exception for grandfathered plans when other coverage is available expires at the start of the 2014 plan year)
  • Summary of Benefits and Coverage
  • No rescissions of coverage except for fraud, misrepresentation, or non-payment
  • Lifetime dollar limit prohibitions on essential health benefits
  • Phase-out of annual dollar limits on essential health benefits, with all limits removed by the 2014 plan year
  • Elimination of pre-existing condition limitations (for children currently and all covered persons starting with the 2014 plan year)
  • Wellness program rules
  • W-2 reporting of health care coverage costs (this only applies if the employer provided more than 250 W-2s for the prior calendar year)
  • Minimum medical loss ratios (this only applies to fully insured plans)
  • Employer shared responsibility (“play or pay”) requirements (generally starting with the 2015 plan year)
  • Employer reporting to IRS on coverage (starting in January 2016, based on the 2015 calendar year)
  • Excise (“Cadillac”) tax on high-cost plans (starting in 2018)

Please contact us for additional information or assistance concerning Grandfather Plans.

Marsha Pfeffer, CSFS, ACBC, LUTCF, CHRS
Sr. Employee Benefits Advisor
marsha@corportatebenefitsnetwork.com
(727) 381-9288 x101