16Grandfathered Plans – Proposed Rules Near Term Reforms (2010) that APPLY to Grandfathered Plans:MLR/Reporting RequirementsExtensions of Dependent Coverage to Age 26Restrictions on RescissionsNo Lifetime Dollar Limits“Restricted” Annual Limits (Group Only)No Pre-Existing Condition Exclusion for Children (Group Only)Near Term Reforms (2010) that DO NOT Apply to Grandfathered Plans:Preventive Services MandateEmergency Service MandateInternal/External Appeals RequirementDirect Access to OB/GYN“Restricted” Annual Limits (Individual Only)No Pre-Existing Condition exclusions for Children (Individual Only)Access to PediatriciansAccess to Primary Care Physicians
17Grandfathered Plans – Proposed Rules Long-Term Reforms (2014) that APPLY to Grandfathered Plans:Prohibition on Excessive Waiting PeriodsAuto-Enrollment for Large GroupsNo Annual Dollar Limits (Group Only)No Pre-Existing Condition Exclusions (Group Only)Long-Term Reforms (2014) that DO NOT Apply to Grandfathered Plans:Adjusted Community RatingEssential Benefit Package MandateCancer Clinical Trials MandateGuarantee Issue (Individual Only)No Pre-Existing Condition Exclusions (Individual Only)No Annual Dollar Limits (Individual Only)Federal Risk Corridor ProgramTransitional Reinsurance ProgramRisk Adjustment Program
18Grandfathered Plans – Proposed Rules Changes that May Relinquish Grandfathering Status:Specified Mergers/AcquisitionsElimination of benefitsAny increase in coinsuranceSpecified Changes to Annual LimitsIncreases in deductibles above statutory thresholdIncreases in co‐pays above statutory thresholdIncreases in OOP limit above statutory thresholdDecrease in employer contribution rate above statutory thresholdChanges that May Not Relinquish Grandfathering Status:Addition of family membersAddition of new employeesModification to conform to federal/state requirementsCessation of coverage of one or more enrolleesPremium adjustmentsVoluntary compliance with PPACATPA changesEarly compliance with PPACA
23Long-Term (2014) Reforms: Benefit Requirements Essential Health Benefits Package*Requires the Secretary to define an essential health benefits package (EHBP) that includes coverage for at least the following general categories:ambulatory patient services;emergency services;hospitalization;maternity and newborn care;mental health/substance use disorder services;prescription drugs;rehabilitative and habilitative services and devices;laboratory services;preventive and wellness services and chronic disease management; andpediatric services, including oral and vision care.* The EHBP will need to be defined in the context of some of the immediate reforms.