You may have a type of health plan that predates the Affordable Care Act. Here’s why it might be a good idea to shop around for other plans.

Back in 2010, to help combat rising health care costs and add protections for Americans just like you, the government passed the Affordable Care Act (ACA). It’s a health care reform law that was meant, in large part, to make affordable health insurance available to more people.

Under the ACA, health insurance companies can’t refuse you coverage or charge you more because you have a preexisting condition, like cancer or diabetes. And all ACA-compliant plans have to offer 10 essential health benefits, including things like emergency services, prescription drugs and preventive care.

But when it was enacted, the ACA exempted certain health plans that were in effect when the law was passed. Those are now referred to as “grandfathered” health plans.

While many Americans now have ACA health plans, some still have grandfathered plans. And those grandfathered plans started being regulated by the ACA on June 17, 2010. Below, learn more about the differences between ACA and grandfathered plans, and which one might work well for you.

Need health insurance? Explore your options now, or contact a licensed insurance agent at 1-844-211-7730.

What is a grandfathered health plan, exactly?

“People might have an individual grandfathered plan, or they may have a plan they bought themselves directly from an insurance broker back in 2010,” explains Caitlin Donovan, senior director of public relations at the National Patient Advocate Foundation in Washington, D.C. “At this point, there may be a significant financial incentive to keep that plan, since most plans that haven’t changed their premiums and cost-sharing structure [since then] would probably be less expensive than a new plan.” (Your premium is your monthly insurance bill.)

She adds that for those with employer-based plans, it may not be obvious whether your plan is considered “grandfathered,” because those plans can still enroll new people.

“They just can’t make substantial changes to the benefit design or the cost of coverage,” says Donovan. “Grandfathered plans are required to alert enrollees of their grandfathered status, but if you missed the alert and want to make sure, your human resources representative should be able to tell you.”

While your grandfathered health insurance plan may cost less on a monthly basis, it may be more costly in the long run, if it doesn’t meet your health needs or those of your family.

So, is it a good idea to stay on your grandfathered plan, or should you switch to an ACA plan? If you have a grandfathered plan, here are 6 reasons why you might consider switching to an ACA plan.

Reason #1: ACA plans come with free preventive care options.

Of course, free anything is good — especially when it comes to health services that could potentially get expensive fast. (These services are free only when delivered by a doctor or other provider in your plan’s network.) And as mentioned above, a range of preventive health services are available via ACA plans, for:

• Adults, including services like:
• Blood pressure screening
• Colorectal cancer screening
• Falls prevention
• Immunizations
• Children, including services like:
• Autism screening
• Depression screening
• Immunizations
• Oral health risk assessment
• Women, including services like:
• Birth control
• Breastfeeding support and counseling
• Maternal depression screening for mothers at well-baby visits
• Urinary tract or other infection screening

“Preventive care is crucial for staying on top of your health care, and it goes beyond your annual weigh-in with your primary care provider,” says Donovan. Those services include things like mammograms, colonoscopies and other cancer screenings. “These services are critical for early detection, and they save lives. In our experience, it doesn’t take very much of a financial barrier to completely deter people from using a service,” she adds.

Reason #2: With ACA plans, you may have the right to appeal a coverage decision.

If you stick with your grandfathered plan, you may be at risk of not being covered by your insurance in certain circumstances, such as medical billing errors. Patients may win appeals that they submit, notes Donovan.

Another way to get health insurance? Enter your ZIP code to search available plans or call a licensed insurance agent at 1-844-211-7730.

Reason #3: With ACA plans, if you have a preexisting condition, you won’t be denied coverage.

A particularly helpful part of ACA coverage is that it doesn’t allow insurance companies to deny you coverage (or charge more) if you have a preexisting condition, something that grandfathered plans may still be able to do.

“Without preexisting conditions covered, you may have a significant waiting period before your coverage kicks in,” explains Donovan. “Not only that, but your insurer may decline to cover not only that condition but also anything related to that condition.” She also adds that a preexisting condition doesn’t have to be a cancer diagnosis.

Reason #4: ACA plans offer access to emergency care.

“You could be the healthiest person in the world, but chances are slim that you’ll go a significant period of time without some type of encounter with the health care system,” explains Donovan.

Under the ACA, in the case of an emergency, health insurance companies can’t charge you more for going to an out-of-network emergency room — although copays, coinsurance and deductibles may still apply.

“If that encounter lands you in the emergency room, you may not be able to afford the bill coming your way if it is not covered by your insurance,” adds Donovan. “Emergency coverage is critical to both your financial and physical health.”

Reason #5: ACA plans have no annual cap on coverage.

Unfortunately, a grandfathered plan may impose an annual cap on how much they will pay for your care in a plan year. However, under the ACA, insurance companies can’t set yearly dollar limits on what they spend for your coverage.

Reason #6: With ACA plans, contraception will definitely be covered.

Under the ACA, health plans must cover contraceptive methods and counseling for all women, as prescribed by a health care provider.

But grandfathered plans may restrict or not offer contraceptive coverage. “For women, a grandfathered plan doesn’t have to cover contraceptive coverage,” says Donovan. “They can also require patients to get a referral to visit an ob-gyn.”

How can I switch from a grandfathered plan to an ACA plan?

If you are thinking of switching from a grandfathered plan to an ACA plan, there are certain time periods when you can do so, including qualifying life events that open a Special Enrollment Period, or SEP. Those include:

• You get married — or you get divorced or legally separated (and lose your health insurance as a result).
• You have a baby or adopt a child.
• You lose your job (and your health insurance with it).
• Someone on your health insurance policy dies, causing you to lose your current plan.
• You move to a different area (as long as you had coverage before you moved).
• You turn 26 (or the maximum dependent age allowed in your state) and can no longer be on a parent’s plan.
• You become a U.S. citizen.

Need a health plan for you or your family? Explore your options now or contact a licensed insurance agent at 1-844-211-7730.

This article contains information that is compiled by UnitedHealthcare or its subsidiaries. UnitedHealthcare does not represent all the information provided are statements of fact. Please consult directly with your primary care physician if you need medical advice.

Sources:

HealthCare.gov. “Preventive care benefits for adults.” Retrieved from https://www.healthcare.gov/preventive-care-adults/ Accessed April 8, 2024

HealthCare.gov. “Preventive care benefits for children.” Retrieved from https://www.healthcare.gov/preventive-care-children/ Accessed April 8, 2024

HealthCare.gov. “Preventive care benefits for women.” Retrieved from https://www.healthcare.gov/preventive-care-women/ Accessed April 8, 2024

HealthCare.gov. “Special enrollment opportunities.” Retrieved from https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ Accessed April 8, 2024

U.S. Centers for Medicare & Medicaid. “Grandfathered plans.” Retrieved from https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Grandfathered-Plans Accessed April 8, 2024

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