Blue Access for Employers

Grandfathered & Non-Grandfathered Plans

Plans that have been active — and have basically stayed the same — since March 23, 2010, might have grandfathered status. As a reminder, grandfathered plans don't have to:

  • Provide certain preventive care at no extra charge
  • Offer a new, simpler way for appealing claims and coverage denials
  • Let employees choose any participating primary care physician (PCP), pediatrician or emergency care

Non-grandfathered plans
must cover preventive care
(no copay, coninsurance or
deductible) for some
in-network doctor visits.

Losing Grandfathered Status

Remember that any changes you make, like lowering your coverage
contribution rate by more than 5%, could cause your status to change.

For example, if you lower your employee-only contribution rate from 65% to
50%, you may lose your grandfathered status.

If your status changes, you may notice:

  • Preventive care rules apply
  • ER care — as well as out-of-network doctor visits — are covered without pre-approval
  • A layperson meaning of an emergency health issue is used
  • Workers can choose any participating PCP or pediatrician
  • Women can see an OB/GYN doctor without pre-approval or referrals

Since this is an overview, detailed information on this
topic — and more — is available.