16 Grandfathered Plans – Proposed Rules Near Term Reforms (2010) that APPLY to Grandfathered Plans: MLR/Reporting Requirements Extensions of Dependent Coverage to Age 26 Restrictions on Rescissions No 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 Mandate Emergency Service Mandate Internal/External Appeals Requirement Direct Access to OB/GYN Restricted Annual Limits (Individual Only) No Pre-Existing Condition exclusions for Children (Individual Only) Access to Pediatricians Access to Primary Care Physicians
17 Grandfathered Plans – Proposed Rules Long-Term Reforms (2014) that APPLY to Grandfathered Plans: Prohibition on Excessive Waiting Periods Auto-Enrollment for Large Groups No 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 Rating Essential Benefit Package Mandate Cancer Clinical Trials Mandate Guarantee Issue (Individual Only) No Pre-Existing Condition Exclusions (Individual Only) No Annual Dollar Limits (Individual Only) Federal Risk Corridor Program Transitional Reinsurance Program Risk Adjustment Program
18 Grandfathered Plans – Proposed Rules Changes that May Relinquish Grandfathering Status: Specified Mergers/Acquisitions Elimination of benefits Any increase in coinsurance Specified Changes to Annual Limits Increases in deductibles above statutory threshold Increases in copays above statutory threshold Increases in OOP limit above statutory threshold Decrease in employer contribution rate above statutory threshold Changes that May Not Relinquish Grandfathering Status: Addition of family members Addition of new employees Modification to conform to federal/state requirements Cessation of coverage of one or more enrollees Premium adjustments Voluntary compliance with PPACA TPA changes Early compliance with PPACA
23 Long-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; and pediatric services, including oral and vision care. * The EHBP will need to be defined in the context of some of the immediate reform s.