You Already Have Health Insurance: Information on Grandfathered Health Plans
How Does the ACA Affect Me if I Already Have Health Insurance?
In most states, if you already have health insurance and you like it, you can keep it until 2017. You can keep your insurance even if it does not follow the ACA. However, your insurance will have to meet ACA regulations by 2017, unless it is a “grandfathered” plan.
If your plan already meets ACA regulations, or if it changes to meet ACA regulations, it can continue.
Some states will not let insurance plans continue if they do not meet the ACA standards.
|States that will not let insurance plans continue if they do not follow the ACA
||Year that the plan will be canceled
|California, Connecticut, Delaware, Maryland, Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont, Washington, Washington, DC
|Colorado, New Mexico
|Arizona, Illinois, Louisiana
|All other states
Your plan is required to tell you if it does not meet the ACA regulations. It must also let you know about the
Health Insurance Marketplace and that money may be available to help you pay for your insurance (in the form of
What if I have COBRA?
COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. COBRA allows people to keep the health insurance they got through their jobs after they:
- Quit their jobs
- Lose their jobs
- Decrease their work hours
Through COBRA, people can usually keep their insurance for 18 months.
If you have COBRA, you are considered to have health insurance. This means you do not have to pay the health insurance
tax. For more information about the health insurance tax, click
The ACA does not affect COBRA. However, some people think it will be cheaper to buy insurance through the Health Insurance Marketplace. There will also be more insurance options through the Health Insurance Marketplace than through COBRA. For more information about the Health Insurance Marketplace, click
What if I am Self-Employed?
If you run a business that generates income, but you do not have employees, you are considered “self-employed.” You are self-employed even if you hire independent contractors to do some work.
People who are self-employed can buy health insurance through the Health Insurance Marketplace. If you have an
individual health plan (not the kind you get through a job, but the kind you buy on your own), you may be able to change to a plan from the Marketplace.
To find out more about the Marketplace, click here. To find out more about changing your individual health plan, go to: https://www.healthcare.gov/what-if-i-want-to-change-individual-insurance-plans/
If you have employees whose income you report on a W-2, you are considered an “employer.” You may be able to get insurance for yourself and your workers through the
Small Business Health Options Program (SHOP) Marketplace. To find out more about small businesses and the ACA, click
What is a Grandfathered Plan?
A grandfathered health plan does not have to follow certain parts of the Affordable Care Act. A health plan is grandfathered if:
- It was created on or before March 23, 2010 (the day President Obama signed the ACA into law)
- It has not made any big changes to premiums or
How Do I Know if My Health Plan is Grandfathered?
You could have a grandfathered health plan if:
- You bought health insurance on your own on or before March 23, 2010; or
- You got your insurance through your job (even if you got your insurance after March 23, 2010). This is because the plan was probably created by your job before March 23, 2010.
To find out if you have a grandfathered health plan:
- Check your plan’s materials.
Beginning September 23, 2010, all health plans have to tell you if they are grandfathered in any written materials.
- Check with your job or your health plan’s benefits administrator.
If you have your insurance through your job, there is a good chance that you have a grandfathered plan. Contact your human resources department to find out if your health insurance plan is grandfathered.
What do Grandfathered Plans NOT Have to Cover?
A grandfathered plan does NOT have to:
- Cover the ACA’s preventative services at no cost to you
The ACA requires most insurance plans to cover certain preventative services. These services include
newborn metabolic screening,
newborn hearing screening, and
genetic counseling for
BRCA testing. A list of the preventive services can be found at: https://www.healthcare.gov/what-are-my-preventive-care-benefits/. Grandfathered plans do not have to cover these services at no cost to you. The preventive services may still be covered by your insurance policy, but you may have a
- Cover the essential health benefits
Essential health benefits are ten health care categories that must be covered by most insurance plans. Grandfathered plans and large employer plans are not required to cover the essential health benefits. However, many of these plans cover most of the essential health benefits already. Also, experts think that grandfathered plans and
large employer plans that do not cover the essential health benefits will probably do so in the future (even though they are not required to). For more information about essential health benefits, click
- Follow new rules when you appeal your insurance plan’s decisions
For many insurance plans, the ACA says you have a right to appeal insurance plan
decisions. This means that you can ask your plan to change its mind about not
paying for a service or treatment. The ACA also has rules about how your plan
must handle your appeal. This does not apply to grandfathered plans. For more
information on appealing health plan decisions and the ACA, go to:
- Let you choose your doctor and have access to
For many insurance plans, the ACA says you can get emergency care at a hospital outside of your plan’s
pre-approval. It also says you can choose your own doctor from within your plan’s provider network, and that you can see an OB/GYN without needing a referral. These do not apply to grandfathered plans. For more information about these rights, go to: https://www.healthcare.gov/how-does-the-health-care-law-protect-me/#part=6
Grandfathered INDIVIDUAL health plans (not the kind you get through work, but the kind you buy on your own) do not have to cover the above list, AND they do NOT have to:
- End annual limits on essential health benefits
Before the ACA, many health insurance plans set an
annual limit (a dollar limit on how much they would spend every year on your benefits). The ACA stops annual limits for essential health benefits. Most grandfathered health plans must follow this. However, grandfathered individual plans do not have to end annual limits on essential health benefits.
- Cover you if you have a pre-existing condition
Under the ACA, most health plans cannot turn you down or charge you more for health insurance if you have a pre-existing condition. A pre-existing condition is a health problem that developed before you joined the health care plan. This does not apply to grandfathered individual health plans.
What Do Grandfathered Plans HAVE to Cover?
All insurance plans, including grandfathered plans, must:
- End lifetime limits on essential health benefits
Before the ACA, many insurance plans set a lifetime limit (a dollar limit on what they would spend for your benefits during the entire time you were part of the plan). The ACA stops insurance plans from having lifetime limits on the essential health benefits. However, insurance plans can still have lifetime limits on other benefits.
- Cover your adult children until they are 26 years old
Before the ACA, insurance companies could take children off their parent’s plan, usually at 19 years of age. The ACA allows children to stay on their parent’s health care plan until age 26. This is called
dependent coverage. However, until 2014, grandfathered group plans can take young adults off of their parent’s plan if the young adult qualifies for his/her own
- Not cancel your insurance just because you made an honest mistake
Before the ACA, if your insurance company found out that you made a mistake on your insurance application, they could take away your insurance and could even make you pay back money they already spent on your care. Under the ACA, insurance companies cannot take away your insurance just because you made an honest mistake on your application. However, insurance companies can take away your insurance if you lie on your application on purpose.
When Does a Grandfathered Plan Stop Being Grandfathered?
A grandfathered health plan stops being grandfathered when it makes big changes to your insurance. These changes usually decrease your benefits or increase your costs. However, grandfathered plans can make routine changes, such as adding benefits or raising premiums to keep up with inflation, and still stay grandfathered.
Where Can I Find More Information
Information from HealthCare.gov about grandfathered plans:
A short publication developed by Families USA with a nice table comparing grandfathered and non-grandfathered plans:
An article by Kaiser Health News describing grandfathered plans: