“One of my concerns, particularly for physicians, is that they may not be aware of the grandfathering rules and might jeopardize their status without realizing the impact of their actions,” says Mr. Kleimann. “The kicker is that once you’ve lost your grandfathered status, you can never get it back.”
Here are four reasons why Mr. Kleimann says practices should maintain their grandfathered status:
1. Nondiscrimination rules in employment. It is not uncommon for orthopedic practices to offer richer healthcare benefits to their physicians than they offer to their staff. However, recent healthcare reforms prohibit discrimination, which means all employees must be eligible for the same coverage and receive the same employer contribution. Plans that are grandfathered are exempt from this requirement. “Whoever is responsible for healthcare within these practices needs to understand the grandfathering provisions, whether it is important to maintain grandfathered status and what changes they are and are not allowed to make in order to maintain it,” he says.
Mr. Kleimann says that if a practice reduces benefits, increases employee contributions, or simply changes insurance carriers, it will likely lose its Grandfathered status and will therefore be required to comply fully with healthcare reform. Mr. Kleimann suggests that practice administrators weigh the value of their Grandfathered status when considering making changes that will jeopardize that status.
2. New reporting on insurance plans. If a practice loses its grandfathered status, it will be subject to new government reporting. Health and Human Services will require reporting on plan design changes (whether the deductible goes up or down, whether the co-pay goes up or down, etc.) and statistics on how many individuals entered or exited a plan throughout the year. Such reports are not required for Grandfathered plans.
3. Payment for care under new insurance plans. Non-grandfathered plans are required to pay 100 percent of preventive care, including annual exams and well-women’s care, which Mr. Kleimann says will cause a rise in premiums. For children up to age 19, the payor must cover care regardless of preexisting conditions, says Susan L. Combs, president of Combs & Company, a New York-based consulting company. Coverage despite pre-existing conditions will expand all patients by 2014.
4. Coverage appeals. An independent appeals process is also required for businesses with Non-grandfathered plans. This appeals process must give plan participants an opportunity to appeal coverage decisions and claim denials, says Mr. Kleimnan. This means that if a plan participant wants to challenge the insurance company’s handling of a particular claim, he or she can appeal using this process. This requirement does not apply to grandfathered plans.
Learn more about Odyssey OneSource.
Read more coverage about how healthcare reform affects orthopedics:
– 7 Healthcare Reform Changes Affecting Orthopedic Surgeons
– 6 Points on New Reform Provisions Going Into Effect Sept. 23
– Healthcare Reform Could Effect Physician Efficiencies in Many Ways
