Grandfathered Plan Checklist of Implications for Group Health Plans

The reform law imposes a number of requirements on group health plans. Most of these will apply to group health plans whether or not they maintain grandfathered status, including:

  • Elimination of lifetime limits on essential benefits
  • Phase-out of annual limits on essential benefits by 2014
  • Extending eligibility for dependents up to age 26*
  • Elimination of pre-existing condition limitations for children under age 19
  • Elimination of all pre-existing condition limitations in 2014
  • Limitation of benefit waiting periods to no more than 90 days in 2014
  • Insurer rebates if minimum loss ratio standards not met (insured plans only)
  • Assessment of “Cadillac plan tax,” if applicable
  • Assessment of employer mandate charge, if applicable

However, some reform requirements will not apply to grandfathered group health plans so long as that status is maintained. These include requirements to:

  • Cover immunizations and certain preventive care without cost sharing
  • Allow member choice of participating primary care physicians and pediatricians**
  • Allow direct access (no referral) to OB/GYN services**
  • Cover emergency services without pre-authorization or increased cost sharing if out of network**
  • Provide internal and external review processes for certain denied claims**
  • Eliminate discrimination in favor of highly compensated individuals
  • Prohibit discrimination based on participation in a clinical trial
  • Apply certain federal rating limitations in 2014 for small group plans (state rating rules will still apply)
  • Provide essential benefits in the small group market in 2014
  • Abide by cost sharing and deductible limits in 2014

* Under PPACA, until 2014 grandfathered group health plans are not required to offer
coverage to dependents who are eligible for employer coverage.
** Most Aetna insured plans already provide these benefits. Current customers should review
their existing plan documents for additional information.

To learn more about grandfathering, access the following links posted on the Department of Labor’s Employee Benefits Security Administration website:
Interim Final Regulation, Table on Applicability of Provisions to Grandfathered Plans, Model disclosure language.

This summary is provided for informational purposes only. This summary should not be
construed as, or relied upon, as legal or any other advice. Employers should consult with their
own legal counsel for a comprehensive explanation of the rules and the proper application
of these rules to their particular situation.