To add to the confusion of the new rules and provisions of the Affordable Care Act, some health insurance plans were “grandfathered” in 2010. This means that all these new rules may not apply to your particular plan. How do you find out if your plan was grandfathered, and if it was, what do you do?

What is a grandfathered healthcare plan?

In 2010, when the Affordable Care Act, otherwise known as Obamacare began to go into effect, the plan that you were on at that point in time was grandfathered. This means that the plan was not required to put into effect many of the provisions of Obamacare. If you have insurance through your employer, the odds are very good that the plan is grandfathered.

Grandfathered healthcare plans do not need to:

  • Cover preventative care without a copay
  • Guarantee your right to appeal a decision you disagree with (such as denial of a test or medication).
  • Protect your choice of doctor and access to emergency room care.

Grandfathered plans (and all other healthcare plans) are required to:

  • End lifetime limits on benefits
  •  Maintain your coverage, even if you made an honest mistake on your paperwork
  • Cover dependents up to the age of 26
  • Provide a short, and easy to read, summary of benefits
  • Spend at least 80% of your premiums on your healthcare; if they don’t, you’ll get a rebate.

If I have a grandfathered plan, should I get Obamacare?

If you have employer’s insurance, there is a chance your plan may be grandfathered. If you buy your insurance on the individual marketplace, however, and currently have basically the same plan that you had in 2010, you will need to consider whether or not you want to purchase insurance through your state’s marketplace for 2014. If you do, you get the benefits that grandfathered plans may not give you: coverage of preventative care without a copay, and the right to appeal a decision your insurance company makes are some pretty big perks.

Some insurance companies are saying, however, that your premiums will go up if you switch to an ACA compliant plan from your grandfathered one.  This is true that some fees built into the ACA will raise premiums, by 2-5%.  But, if you have an individual plan, you may be able to get a federal subsidy to help with the cost of those premiums, bringing the total cost to something more affordable than what you’re paying now.

But all in all, there’s no easy, one size fits all answer. You’ll need to call your current provider, find out if your plan is grandfathered, and find out if it's expected to stay grandfathered in 2014. Ask if they currently cover preventative care without a copay—many plans already do this—and ask about the process to appeal a decision. When you ask what would happen if you had to go to an emergency room that was out of network, you may find that your grandfathered plan is serving you very well, and decide not to make any changes, or you may find there's some real room for improvement.

Will my grandfathered plan ever lose its grandfathered status?

It’s hard to say. If it keeps roughly the same benefits, and the amount that the insurer pays for your care (which is different than the cost of your premiums) doesn’t change dramatically, it may not. If you get your insurance through an employer, your insurance plan may be grandfathered, and stay that way, even if you purchase it after 2010, since the plan itself may not have changed.

If your plan is grandfathered, it’s required to say so in all documentation. If you call and ask, a representative should be able to confirm whether or not your insurance plan falls into this category.

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