Grandfathered Plans under the Affordable Care Act

One of the more important and popular provisions of the Affordable Care Act is the expansion of access to certain recommended preventive care services – including flu shots – for patients at no additional charge to them. However, many health plans that existed on the day the ACA was enacted, March 23, 2010, known as “grandfathered plans,” are exempted from such provisions. These exemptions were allowed in order to make sure that people who were satisfied with the coverage they had were able to keep that coverage in place.

If a patient had health coverage from a plan that existed on March 23, 2010 – and that has covered at least one person continuously from that day forward – the plan may be considered a “grandfathered” plan. This would be the case whether the patient was covered by an individual health insurance policy or by a job-based health plan that was established by the employer before March 23, 2010 – even if the patient enrolled in the job-based plan after March 23, 2010. A grandfathered health plan isn’t required to provide those recommended preventive services at no additional charge to patients.

To maintain its grandfathered status, a plan had to be in existence as of March 23, 2010 and not make any major changes that reduced benefits or increased costs to consumers since then. If a plan loses its grandfathered status, all of the Affordable Care Act consumer protections would apply to a patient when the plan begins a new plan year or policy year.

To find out if a health plan is grandfathered, a patient may:

• Check the 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 the patient’s employer or health plan’s benefits administrator. If a patient is in a group health plan, the date s/he 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.