GROUP HEALTH PLANS

GRANDFATHERING OF GROUP HEALTH PLANS

 

As employers make changes to their plan’s benefits and contributions, the number of “grandfathered” plans has significantly decreased over the last year. Plans that lose grandfathered status must comply with additional provisions of the law; however, many employers within our market are not significantly impacted by the loss of this status. This should be analyzed each year.

 

Current Mandates for Grandfathered Plans

  • Extend coverage to dependents up to age 26; plan may choose to limit eligibility so that dependents eligible for other employer-sponsored coverage are not eligible.
  • Plans may not impose a pre-existing condition exclusion for any individual under age 19.
  • Plans may not apply any lifetime limit on the dollar amount of essential health benefits for any individual; plans may apply an annual limit as allowed by the law.
  • Plan may not terminate coverage retroactively except in the case of fraud or an intentional misrepresentation of material fact.

 

Current Mandates for Non-Grandfathered Plans

  • Extend coverage to dependents up to age 26 regardless of eligibility for other employer-sponsored coverage.
  • Plans may not impose a pre-existing condition exclusion for any individual under age 19.
  • Plans may not apply any lifetime limit on the dollar amount of essential health benefits for any individual; plans may apply an annual limit as allowed by the law.
  • Plan may not terminate coverage retroactively except in the case of fraud or an intentional misrepresentation of material fact.
  • Provide coverage for certain preventive care services without cost-sharing, including preventive services rated A or B by the U.S. Preventive Task Force.
  • Plans must allow enrollees to select their primary care provider (PCP), or pediatrician in the case of a child, from any available participating primary care provider.
  • Plans are prohibited from requiring authorization or referral by the plan for a female patient who seeks coverage for obstetrical or gynecological care by a specialist in these areas.
  • Plans are prohibited from requiring prior authorization or imposing increased cost-sharing for emergency services.
  • Plans must comply with the law’s internal claims appeals process and external review procedures

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