[Editor’s note: With significant portions of the Affordable Care Act to be implemented starting on Jan. 1, 2014, the Kokomo Tribune is running a series that explores how the personal responsibility mandate, the expansion of Medicaid and the new health exchanges will affect consumers.]
Q: My employer has dubbed our coverage “grandfathered in” and does not cover the types of medical care I want from my insurance. Will the Affordable Care Act help me? Will my insurer ever have to provide coverage of, for example, no copay/deductible for preventive medicine?
A: Under the provisions of the Affordable Care Act any health insurance plan that existed before March 2010 does not have to meet all the requirements of the law.
Craig Dunn, a financial planner for Liberty Financial, said grandfathered plans were those plans that were in existence March 23, 2010, and have stayed basically the same.
He said those plans must still end lifetime limits, end arbitrary cancellations, cover adult children up to age 26, and provide a summary of benefits and coverage.
“They don’t have to offer preventive care for free, guarantee your right to appeal and protect your choice of doctors and access to emergency care,” Dunn said. “While the ACA does offer insured and non-insured people additional rights and benefits, it also provides a legal framework that may allow your employer to protect its own bottom line by asserting its own rights under the law.”
Kathy Young, CEO of St. Joseph Hospital, said if an insurer or employer makes significant changes to a plan’s benefits or how much members pay through premiums, co-payments and deductibles, then the plan loses the grandfathered status.
“The regulations spell out how much plans can change the amount paid by workers or employers before losing their status,” Young said. “A grandfathered plan has to follow some of the same rules other plans do under the ACA, but it doesn’t have to follow all of them.”
Grandfathered plans don’t have to cover preventive care for free, guarantee right to appeal, protect choice of doctors and access to emergency care and be held accountable to Rate Review for excessive premium increases, she said.
In 2013, 36 percent of people who get coverage through their jobs are enrolled in a grandfathered health plan, down from 48 percent in 2012 and 56 percent in 2011, according to the Kaiser Family Foundation’s most recent Employer Health Benefits Survey.
Young said more plans are expected to lose grandfathered status over time.
Readers can submit their questions on the Affordable Care Act to Enterprise Editor Ken de la Bastide at firstname.lastname@example.org or by mailing them to Kokomo Tribune, care of Ken de la Bastide, 300 North Union St., Kokomo, IN, 46901.