Grandfathered Health Plans

The Affordable Care Act exempts most plans that existed on March 23, 2010 — the day the law was enacted — from some of the law’s consumer protections. This preserves consumers’ rights to keep the coverage they already had before health reform.

What This Means for You

If you have health coverage from a plan that existed on March 23, 2010 — and that has covered at least one person continuously from that day forward — your plan may be considered a “grandfathered” plan.

This is true whether you are covered by an individual health insurance policy that you had on that date, or you are covered by a job-based health plan that your employer established before March 23, 2010. This is true even if you enrolled in that job-based plan sometime later.

A grandfathered health plan isn’t required to comply with some of the consumer protections of the Affordable Care Act that apply to other health plans that are not grandfathered.

Here’s a look at which consumer protections do and don’t apply to grandfathered plans:

Consumer Protections in the Health Care Law that DO Apply to Grandfathered Plans

Many of the law’s consumer protections that took effect on September 23, 2010 apply to all plans, whether they are grandfathered or not.

Please note that these consumer protections will be added to your plan when it begins a new plan year or policy year on or after September 23, 2010.

ALL health plans:

• are prohibited from applying lifetime dollar limits to key health benefits.
• are not permitted to cancel your insurance coverage solely because of an honest mistake that you or your employer made on your insurance application.
• must extend dependent coverage to your adult children until they turn 26 years old with one temporary exception. (Until 2014, grandfathered group plans do not have to offer dependent coverage up to age 26 if a young adult is eligible for group coverage outside their parent’s plan)

Consumer Protections in the Health Care Law that DO NOT Apply to Grandfathered Plans

Unlike other health plans, job-based plans and grandfathered plans are not required to:

• provide certain recommended preventive services at no additional charge to you.
• offer new protections when you are appealing claims and coverage denials.
• protect your choice of health care providers and your access to emergency care.

Consumer Protections in the Health Care Law that also DO NOT Apply to Grandfathered INDIVIDUAL Plans

Grandfathered individual health insurance policies — not the kind you get through work — in addition to the exclusions above are not required to adopt the provisions of the law that:

• phase out annual dollar limits on key benefits.
• eliminate pre-existing condition exclusions for children under 19 years old.

Some Important Details

Grandfathered plans can lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. Read more about changes that will cause a health plan to lose grandfathered status.

Although grandfathered work-based plans can make only limited changes to the percent of the premium the employer contributes, grandfathered plans may still increase their total premium amount without losing grandfathered status.

If your plan loses its grandfathered status, all of the Affordable Care Act consumer protections would apply to you when your plan begins a new plan year or policy year.

To find out if your health plan is grandfathered:

• Check your plan’s materials. Beginning with the first plan or policy year starting on or after September 23, 2010, health plans must disclose their grandfathered status in any plan materials describing the plan’s benefits that are distributed to beneficiaries or primary subscribers. These materials must also contain contact information for questions and complaints.
• Check with your employer or your health plan’s benefits administrator. If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to a grandfathered group plan after March 23, 2010.

If you experience significant changes in the benefits you receive or the costs you pay and you have a grandfathered employer-based group health plan, contact the Employee Benefits Security Administration, U.S. Department of Labor at www.askebsa.dol.gov or call 1-866-444-3272.

For More Information

• Read some FAQs for employers regarding grandfathered health plans.
• Find detailed technical and regulatory information on grandfathered health plans.
• HealthCare Blog: Keeping the Plan You Like.
• Fact Sheet: Keeping the Plan You Have.

Posted on: December 1, 2010

Last updated: August 20, 2012