Consumers In Grandfathered Plans Can Face Higher Costs For Preventive Benefits
Judy Naillon called her insurer several months ago to find out why she was being charged $35 every month for birth control pills. Her friends said they were getting their pills for free under the federal health law.聽Why wasn鈥檛 she getting the same deal?
The insurance rep explained that was because the plan Naillon聽and her husband had through his job聽was 鈥溾 under the health聽law. That meant the plan didn鈥檛 have to cover preventive services, including contraceptives, with聽no charge to consumers聽as Obamacare聽requires of other plans.
Naillon, 33, would have to continue to pay聽a share of the cost聽of her pills, and the plan wouldn鈥檛 pay if she wanted to switch to an intrauterine device either. There also was no coverage for an annual physical.
鈥淚鈥檓 just really frustrated,鈥 says the Wichita, Kan.,聽piano and violin teacher. When her husband took a new marketing job last fall, 鈥淚 thought that surely all these insurers must now be covering these benefits.鈥
About a quarter of insured workers remain covered by grandfathered plans, according to the . (KHN is an editorially independent program of the foundation.) These plans were in existence when the and聽haven鈥檛 changed their benefits or consumer costs significantly since then.
In addition to not being required to cover preventive benefits聽without charge, grandfathered plans are exempt from some other health law requirements. They don鈥檛 have to guarantee members鈥 rights to appeal a decision by their health plan, for example, and may charge consumers higher copays or coinsurance for out-of-network emergency services.聽They also don鈥檛 have to comply聽with the law鈥檚 limits on (currently $6,600 for someone in an individual plan and $13,200 for families), so聽consumers in these plans may be on the for more of their medical care.
When the health law passed, President Barack Obama sought to reassure anxious consumers by promising聽that 鈥渋f you like your health care plan, you can keep it.鈥澛 Since then, the number of grandfathered plans has steadily declined. In 2011, 72 percent of companies that offered health insurance had at least one grandfathered plan; by 2014 that number had declined to 37 percent, according to .
The decline isn鈥檛 surprising, say benefits experts.
鈥淟arge employers make changes every year to improve care and reduce costs,鈥 says Steve Wojcik, vice president of public policy at the National Business Group on Health, an advocacy group representing large employers鈥 interests.
Some big self-funded companies may keep generous grandfathered plans as a recruiting and retention tool, says Joe Kra, a partner and actuary at human resources consultant Mercer.
Smaller employers are more likely than large ones to be grandfathered at this point, Wojcik says. Small firms typically buy a plan from an insurer that pays their claims, unlike larger companies that often design their own plans and pay their employees鈥 claims directly.
Individual plans can also be grandfathered.
Some health policy experts have two words for the demise of grandfathered plans: Good riddance. Lacking many consumer protections and generally subject to weaker regulation, they aren鈥檛 necessarily good options for people who have health problems.
But they can be a good deal for younger and healthier people. 鈥淕randfathered plans are more likely to hang onto people who are low risk,鈥 says Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.聽However, on the individual market, if healthy people stay in grandfathered plans, that tends to leave sicker people in the comprehensive plans that comply with the health law.
From an employee鈥檚 perspective, what grandfathered plans may lack in consumer protections they may make聽up for in聽reduced cost sharing, Kra says.
In order to retain their grandfathered status, for example, plans are limited in how much they can increase copayments and deductibles, among other things. That means if someone had a $20 copayment in 2010, the copayment today could be no more than $26 next year, Kra says. Likewise, a $500 deductible could be no more than $652.
鈥淚f an employee is in a grandfathered plan, they鈥檙e one of the fortunate minorities,鈥 Kra says.
Naillon probably wouldn鈥檛 agree with that statement.
鈥淓ven though my doctor would like to do a physical and run labs, I can’t afford to have those services,鈥 she says.
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