Is the new insurance company pulling a fast one?

November 29, 2012 9:08 AM

US-InsuranceFilter: How do I know if an insurance plan is grandfathered under the new ACA "coverage of young adults" policies? The insurance company is acting like it is, but won't answer direct questions about being grandfathered.

I'm under 26, working full-time, and eligible for (though not currently covered by) insurance through my job. I'd like to continue to be covered by my dad's health insurance, which will changing in January with his new job.


My understanding is that the ACA says insurance plans must cover all children under the age of 26 (as explained here [PDF]), but plans can be grandfathered in and don't have to do this until 2014. This new insurance plan is apparently grandfathered in, and says that they don't cover children who are eligible for insurance through their workplace. Fair enough.

But then I ran across this page on healthcare.gov, which says

Beginning with the first plan or policy year starting on or after September 23, 2010, health plans must disclose their grandfathered status in any plan materials describing the plan’s benefits that are distributed to beneficiaries or primary subscribers.

Well, even though our giant info packet explains that they won't cover me, it never says that it's a grandfathered plan. So we called to ask directly, and the insurance rep just said that's the way they've been doing things for the last year.

Are they trying to pull a fast one here? Normally I'd assume the disclosure was buried in fine print somewhere, but the weird answer to my simple yes-or-no question makes me wonder if they can really restrict coverage like this. Given that they won't actually tell us if it's a grandfathered plan, what should be our next step?

posted by Nonsteroidal Anti-Inflammatory Drug to law & government (8 answers total)

You next call should be to your father's HR person who handles health benefits. That person is going to be able to call in much higher in the insurance plan food chain.

Call center agents are reading the script and do not have any decision power over who's included in coverage. Your plan coordinator is going to have a much greater likelihood of getting an answer.
posted by 26.2 at 9:38 AM on November 29, 2012

Your plan coordinator is going to have a much greater likelihood of getting an answer.


I misspoke here - by "insurance rep", I mean that we talked to someone who works for the new company. They and the rest of "Company X Insurance Hotline" are ostensibly the people to answer any insurance questions.
posted by Nonsteroidal Anti-Inflammatory Drug at 9:47 AM on November 29, 2012

I work for a health insurance company but probably not yours (we recommended covering everybody under 26 since 2010) and I'm not speaking for mine.

I have no idea if that are trying to pull a fast one but you are correct that they need to disclose whether or not they are grandfathered pretty much everywhere. (That doesn't mean everybody is doing it.) If you feel like they aren't, I'd contact the number that they should have on their materials.

If the rep is not giving you the information you need, what you want to look for on the plan materials is the Plan Administrator. If they haven't given you that contact information on your plan materials, contact EBSA at 1-866-444-3272.
posted by MCMikeNamara at 9:48 AM on November 29, 2012 [1 favorite]

You should reach out to your state Department of Insurance about this, since this insurance company is out of compliance with a federal law by not disclosing. Tipping off the plan administrator for the company you are dealing with that you intend to do just that will probably get you the info you need in about 30 seconds.
posted by deliciae at 10:59 AM on November 29, 2012 [4 favorites]

The scenario you are describing, where a plan does not cover dependent children under 26 with their own employer coverage available, is legitimate, if the plan is a grandfathered plan.

The Summary Plan Description for the plan should have the plan's grandfather status stated in an amendment (unless the plan is restated at the start of each plan year). Have you checked the latest amendments?
posted by FergieBelle at 11:35 AM on November 29, 2012

Seconding contact your DOI. Here is a Linky to help you do that.
posted by Michele in California at 1:10 PM on November 29, 2012

If they haven't given you that contact information on your plan materials, contact EBSA at 1-866-444-3272.

The EBSA essentially reiterated what everyone here said - they really should be telling me this, etc. The man I spoke with also said that this plan is almost certainly a grandfathered one, so I'll probably give the company hotline a call again. We've managed to get the same person for both previous calls, but maybe we can connect with someone else.


Tipping off the plan administrator for the company you are dealing with that you intend to do just that will probably get you the info you need in about 30 seconds.

I'll be sure to mention that, thanks.
posted by Nonsteroidal Anti-Inflammatory Drug at 6:44 AM on November 30, 2012 [1 favorite]

Followup: My dad somehow verbally judo-ed HR into covering me, so I didn't bother getting all the documentation they should have sent us.

Thanks, dad!
posted by Nonsteroidal Anti-Inflammatory Drug at 12:03 PM on January 9