Learn About the Affordable Care Act

Grandfathered Plan

The Affordable Care Act (ACA) makes many new rules about what insurance compaies can do, and what insurance plans must cover. These rules go into effect between now and January 2014. All of the rules apply right away to new plans, but only some apply to 'grandfathered' plans.

A plan is grandfathered if it:

  • existed on March 23, 2010 (the day before the ACA became law), and
  • has not been changed in a big way.

A big change would be the plan covering fewer health services, or making you pay more for services. Once a grandfathered plan makes a big change, it becomes a new plan and all of the rules apply to it.  To know if your plan is grandfathered, check with your employer or your insurance plans.

Rules that apply to all plans (both grandfathered and new plans):

Already:

  • Children under 19 years old cannot be denied insurance due to their health.
  • Insurers cannot limit how much they will spend over your lifetime on essential health benefits. Essential health benefits are the basic health services that everyone needs.
  • Insurers cannot cancel your health insurance if you get sick. They can only cancel your insurance if you lie to them.
  • Family insurance plans must cover kids until they turn 26.
    • Note: Grandfathered plans only have to cover young adults who cannot get insurance through their own employer.
  • Insurers have to give you a parital refund if they do not spend at least 80% of premiums on medical services.

Beginning 2014:

  • Adults cannot be denied insurance based on their health.
  • Insurers cannot make you wait more than 90 days from the time you apply for health insurance.
  • Insurers cannot limit how much they will spend each year on essetial health benefits for you.

Rules that only apply to new plans:

Already:

  • Insurers must cover 100% of the cost of preventive services. This includes services like immunizations, certain cancer screenings, and diabetes screening. A complete list can be found here: http://www.healthcare.gov/law/about/provisions/services/lists.html
  • You can appeal your insurer's claims decisions to an internal insurer review board.
  • You can appeal your insurer's claims deicisions to an independent outside review board once you have gone through their internal process.

Beginning 2014:

  • Insurers cannot charge you more because of your health status or your gender.
  • Your premium can only be increased based on your:
    • age
    • family size
    • where you live
    • whether you use tobacco
  • Insurers must renew your insurance unless you commit fraud.
  • Insurers must cover at least 60% of the cost of essential health benefits.
  • Group health plans, such as insurance offered by employers or unions, cannot have deductibles higher than:
    • $2,000 for individual plans
    • $4,000 for family plans

 

Have a question?

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