Child_6549085What is a grandfathered plan?

Most health insurance plans that existed on March 23, 2010 are eligible for grandfathered status and therefore do not have to meet all the requirements of the health care law. But if an insurer or employer makes significant changes to a plan’s benefits or how much members pay through premiums, copays or deductibles, then the plan loses that status.

What rules does a grandfathered plan have to follow?

A grandfathered plan has to follow some of the same rules other plans do under the ACA. For example, the plans cannot impose lifetime limits on how much health care coverage people may receive, and they must offer dependent coverage for young adults until age 26. They also cannot retroactively cancel your coverage because of a mistake you made when applying, a practice known as a rescission.

However, there are many rules grandfathered plans do not have to follow. For example, they are not required to provide preventive care without cost-sharing and can still impose annual dollar limits. In addition, they do not have to offer a package of “essential health benefits” that individual and plans must offer beginning in 2014.

Most people have already lost their grandfathered status due to various reasons.  Ohio Health Benefits can review your plan to identify if you are or are not still grandfathered and help recommend if you should maintain this status.


What are “Essential Health Benefits”?

The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace, and all Medicaid state plans must cover these services by 2014.


What are Metallic Levels of Benefits?

PPACA defines four metal tiers of coverage for purposes of the essential health benefits package: Bronze, Silver, Gold, and Platinum. There is also a catastrophic level of coverage. PPACA requires all plans issued in the individual and small group markets, both in the Exchange and outside of the Exchange, to meet the actuarial standards of one of these metal tiers of coverage or catastrophic coverage. To participate as a qualified health plan in an Exchange, PPACA requires, among other things, that such plans offer, at a minimum, coverage at the silver and gold levels of coverage.

Definition of Levels:

Bronze: means a level of coverage designed to provide benefits that are the actuarial equivalent of 60 percent of the full actuarial value of the benefits provided under the plan

Silver: (70 percent)

Gold: (80 percent)

Platinum: (90 percent)

Catastrophic only: allows for a separate catastrophic-only policy which would provide the essential health benefits package. The plan must offer coverage for at least three primary care visits. Individuals eligible for enrollment must not have attained the age of 30 before the beginning of the plan year.



To view the complete Ohio Health Benefits Summer 2013 newsletter click here.