Application Of The New Health Reform Provisions Of Part A Of Title Xxvii Of The Phs Act To Grandfathered Plans (Page 2 of 4) in pdf

This chart contains an illustrative summary of some of the new health reform provisions and does not cover all the

specifics of the provisions. This chart provides an informal explanation of the new health reform provisions and should

not be considered legal advice or interpretive guidance.

§2708 Prohibition on excessive

Prohibits any waiting periods that exceed 90

Applicable

waiting periods

days for group health plans and group health

insurance coverage.

§2709

Coverage for individuals

Prohibits health insurance issuers from dropping

Not applicable

participating in approved clinical

coverage because an individual (who requires

trials

treatment for cancer or another life-threatening

condition) chooses to participate in a clinical

trial. Issuers also may not deny coverage for

routine care that they would otherwise provide

because an individual is enrolled in a clinical

trial.

§2711 No lifetime or annual

Prohibits group health plans and health

Prohibition on lifetime limits:

limits

insurance issuers offering group or individual

Applicable

health insurance coverage from establishing

lifetime limits and annual limits on the dollar

Prohibition and limits on annual

value of benefits. Prior to 2014, plans and

limits: Applicable to grandfathered

issuers may establish certain restricted annual

group health plans and group

limits (as defined in regulations).

health insurance coverage; not

applicable for grandfathered

individual health insurance

coverage.

§2712 Prohibition on rescissions

Group health plans and health insurance issuers

Applicable

may not rescind health coverage after coverage

begins except in the case of fraud or intentional

misrepresentation.

§2713 Coverage of preventive

Group health plans and health insurance issuers

Not applicable

health

offering group or individual health insurance

coverage must cover certain preventive services,

immunizations, and screenings, without any cost

sharing.

§2714 Extension of dependent

Group health plans and health insurance issuers

Applicable

coverage

offering group or individual health insurance

coverage that provide dependent coverage must

continue to make such coverage available to

children until age 26.

After the amendments made by the Affordable Care Act, there are two PHS Act sections 2709. The first

section 2709 was PHS Act section 2713 before the amendments made by the Affordable Care Act and was

redesignated PHS Act section 2733 by section 1001(3) of the Affordable Care Act and then, as PHS Act

section 2733, was again redesignated by section 1562(c)(10) of the Affordable Care Act as PHS Act section

2709. The second section 2709 was added by section 10103 of the Affordable Care Act and relates to

coverage for individuals participating in approved clinical trials. Grandfathered health plans are subject to

the first PHS Act section 2709 because as PHS Act section 2713 it was part of the PHS Act before the

enactment of the Affordable Care Act. However, grandfathered health plans are not subject to the second

PHS Act section 2709.

For a group health plan or group health insurance coverage that is a grandfathered health plan for plan

years beginning before January 1, 2014, PHS Act section 2714 is applicable in the case of an adult child

only if the adult child is not eligible for other employer-sponsored health plans coverage. The interim final

regulations relating to PHS Act 2714, published in 75 FR 27122 (May 13, 2010), and these interim final

regulations clarify that, in the case of an adult child who is eligible for coverage under the employer-

sponsored plans of both parents, neither parent’s plan may exclude the adult child from coverage based on

the fact that the adult child is eligible to enroll in the other parent’s employer-sponsored plan.

Application Of The New Health Reform Provisions Of Part A Of Title Xxvii Of The Phs Act To Grandfathered Plans Page 2

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