Grandfathered Plans

Group health plans in existence before enactment of the Affordable Care Act (ACA) could opt to be "grandfathered" and postpone implementing various ACA requirements. Plan sponsors may make only minimal changes to these plans to retain grandfathered status.

Articles


FAQs


Government Resources

  • Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections, CMS, EBSA, HHS, IRS, 11/18/2015 Final rules make no major changes from the interim rules but incorporate FAQ and other informal guidance since 2010, applicable January 1, 2017.

  • FAQs About ACA Implementation Part VI, EBSA, 4/1/2011 Grandfathered plans, transferring employees from one grandfathered plan to another, cost sharing for brand-name prescription drugs and generic alternatives, when amendments to plan terms that will cause plan to relinquish grandfather status become effective, retiree plan contribution rate

  • Amendment to the Interim Final Rules for Group Health Plans and Health Insurance Relating to Status as a Grandfathered Health Plan Under the PPACA, IRS, EBSA, CMS, HHS, 11/17/2010 Allows all group health plans (self-funded and fully-insured) to switch insurance companies for the same coverage and remain grandfathered so long as the structure of the coverage doesn’t violate one of the other rules for maintaining grandfathered plan status

  • FAQs About ACA Implementation Part IV, EBSA, 11/1/2010 Whether a grandfathered plan must provide the disclosure statement every time it sends out a communication, such as an EOB (explanation of benefits), to a participant or beneficiary; lifetime limit on reimbursement of expenses for special treatment and therapy of eligible employees’ children with physical, mental, or developmental disabilities

  • FAQs About ACA Implementation Part II, EBSA, 10/8/2010 Grandfathered plans (plan changes other than the six specifically described, employer contribution on a tier-by-tier basis, how grandfather rules affect wellness programs), dental and vision excepted benefits, rescissions

  • FAQs About ACA Implementation Part I, EBSA, 9/20/2010 Grandfathered health plans including multiemployer plan employer contribution rate, definition of dependent child, internal appeals and external review, out-of-network emergency services and balance billing

  • Interim Final Rules for Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan Under the PPACA, IRS, EBSA, CMS, HHS, 6/17/2010 Interim final rule for determining when changes to a health plan cause the plan to lose its grandfathered status. Any of six changes (measured from March 23, 2010) are considered to change a health plan so significantly that they will cause a plan to relinquish grandfather status. These six changes are: 1) Elimination of all or substantially all benefits to diagnose or treat a particular condition; 2) Increase in a percentage cost-sharing requirement; 3) Increase in a deductible or out-of-pocket maximum by an amount that exceeds medical inflation plus 15 percentage points; 4) Increase in a copayment by an amount that exceeds medical inflation plus 15 percentage points (or, if greater, $5 plus medical inflation); 5) Decrease in an employer’s contribution rate towards the cost of coverage by more than 5 percentage points; 6) Imposition of annual limits on the dollar value of all benefits below specified amounts.

  • Model Disclosure Notice, EBSA, 6/17/2010 Sample model language can be used to satisfy grandfathered plan disclosure requirement to notify a participant or beneficiary that the plan believes it is a grandfathered health plan and must provide contact information for questions and complaints

  • Table of Provisions Applicable to Grandfathered Plans, DOL, 6/17/2010 Summary of whether or not ACA provisions apply to grandfathered plans