Originally Posted by frank
I am on medicare and my wife is on a grandfathered plan with our insurance company. What is the difference or benefit of a grandfathered and not grandfathered. any ideas? might seem like a stupid question, but I really don't know.
This is a really good question.
Grandfathered health plans avoid 13 provisions of the Affordable Care Act:
- New Government Reports – Since Obamacare became law, employers are required to provide the State Insurance Commissioner and the Secretary of Health and Human Services specific information about enrollment, claims and payment policies for their health plans.
- Claims Review – The PPACA has expanded the internal claims review process, which would apply to any new plans that went into place after March 23, 2010.
- Annual Reports – Newer plans must provide the Secretary of Health and Human Services with an annual report that details how the plan will improve health outcomes.
- First Dollar Coverage – All plans must provide first-dollar coverage for any preventive care services. These include an annual check-up and blood test. For women, it also includes a mammogram after age 35 and an annual gynecological exam.
- Premium Rules – One provision of Obamacare, known as the "Fair Health Insurance Premiums," requires that insurance premiums can only vary by an individual's age at a maximum 3:1 ratio and for tobacco usage at a 1.5:1 ratio. Rates may also change based on geographic rating area and the type of coverage (family or individual.)
- Emergency Services — Effective on March 23, 2010, all new insurance policies will cover emergency services without prior authorization.
- Guaranteed Access — Perhaps one of the most groundbreaking changes to healthcare access, the "Guaranteed Availability of Coverage" provision obligates insurance providers to accept every individual or employer who applies for insurance.
- Any Willing Provider – This provision stipulates that plans may not discriminate against any willing provider of medical services if they operate within the scope of their practice.
- Health Status — this provision prohibits plans from discriminating against certain participants based on the status of their health.
- Essential Benefits — Effective with the enactment of Obamacare, new plans must provide "essential benefits" to all participants, as outlined and mandated by the law.
- Clinical Trials — The PPACA also mandates that individuals who participate in approved clinical trials will also receive coverage from their insurance plan.
- Preventive Care — In addition to ensuring that all health insurance plans include preventative care, Obamacare mandates that all preventive health services are covered 100% by the insurer without any cost sharing.
A grandfathered plan:
May not significantly cut or reduce benefits
May not raise co-insurance charges
May not significantly increase co-payment charges
May not significantly raise deductibles
May not significantly decrease the employer contribution
May not tighten the annual limit of what the insurer will pay
May not change insurance providers