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Benefit Mandates Under Healthcare Reform

The Affordable Care Act imposes a number of requirements on group health plans regardless of whether or not a plan is deemed a grandfathered or non-grandfathered health plan. However, some reform requirements do not apply to grandfathered plans as long as that status is maintained.


Provided below is a quick summary of those benefits or provisions that should already be included in plan(s), regardless of grandfathered status, and those that will need to be added (in the future if not already included today), upon loss of grandfathered status. This is a summary only.



Applicable to Both Grandfathered and Non-Grandfathered Plans

Applicable to Non-Grandfathered Plans Only

(In addition to the Reforms to the Left or Upon Loss of Grandfather Status)

Annual and Lifetime dollar limits are not allowed to be placed on essential health benefits

Coverage of certain immunizations and preventive care services (including women's preventive care services and coverage for contraceptive services) without cost share when services are provided in network

Eligibility of dependent children up to age 26, including coverage of married children

Patient Protections, including choice of primary care provider, GYN, as well as coverage of out-of-network emergency care

Pre-existing condition limitations/exclusions are no longer allowed, regardless of age

Expanded requirements associated with claims and internal and external review processes

Coverage may not be rescinded, except in the case of intentional misrepresentation or fraud

In-Network Out-of-pocket maximum requirements

Waiting periods cannot exceed 90 days

Guidelines around coverage that is required when an individual is participating in an approved clinical trial

Health FSA Salary reduction are limited to $2,550

Coverage of over-the-counter medications no longer covered without a doctor’s prescription for Flexible Spending Accounts (FSA), Health Reimbursement Arrangement (HRA), Health Savings Account (HSA) and Archer Medical Savings Account (Archer MSA) plans

Employers who maintain prescription drug plans for their Medicare Part D eligible retirees are no longer able to deduct these expenses



This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.