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Presenters: plan changes would end 'grandfathered' status, meaning copays would count toward out-of-pocket maximums
Summary
Presenters told the committee that changing current plans or adding new plans would remove grandfathered status under the ACA; as a result, copayments and prescription copays would count toward out-of-pocket maximums, which could reduce net out-of-pocket costs for some employees despite higher nominal maximums.
Consultants explained that current Metro PPO design is partially grandfathered: copays and prescription copays do not count toward the $1,000 out-of-pocket limit under the existing plan design. They cautioned that making changes to the current PPO or adding a new plan would cause the plans to lose grandfathered status and, under Affordable Care Act rules, preventive services and copays would count toward the out-of-pocket maximum.
"In a new lower cost plan or if you take the current PPO plan and you remove the language... it's no longer grandfathered," Kelly Lewis (Deloitte) said. Staff added that if the plan is no longer grandfathered, copays would count toward the out-of-pocket maximum and the plan would “operate as a true out-of-pocket max unlike it does now,” which could offset some apparent increases in numeric maximums depending on the configuration of copays and coinsurance.
