Survey Research Solutions - Broker



Survey Research Solutions - Broker
Survey Research Solutions
6300 Olson Memorial Highway MN015-E135
Golden Valley, MN 55427
Plan Sponsor - Grandfather Status Certification
As 2014 approaches, UnitedHealthcare is conducting a survey of its small group health insurance
customers to determine which ones are grandfathered as defined by the Patient Protection and Affordable
Care Act (PPACA). This survey will enable UnitedHealthcare to comply with the financial reporting
requirements of PPACA and to plan our 2014 renewal strategy with respect to the 2014 insurance
requirements that may be grandfathered.
A grandfathered group health plan is a plan that was in effect on 3/23/2010, and since that date (1) has
not made any plan changes that would cause grandfathered status to be lost and (2) has complied with
the notice and recordkeeping requirements. Please refer to the summary on the following pages for a
more detailed explanation of the grandfather requirements.
Please complete this form and return it to UnitedHealthcare at the address below before September
7, 2012: Survey Research Solutions, OptumHealth, 6300 Olson Memorial Highway, MN010-E135,
Golden Valley, MN 55427
Failure to return this form before September 7, 2012 will result in UnitedHealthcare's considering your
plan to be non-grandfathered, and will require benefit changes to comply with PPACA beginning with
renewal effective dates on January 1, 2014.
___ Plan sponsor certifies that its group health plan is a grandfathered health plan and wishes to
maintain its grandfathered status. Plan sponsor agrees to notify UnitedHealthcare at least 30 days in
advance of any plan changes it intends to make (including a more than 5% reduction in its premium
contribution rate that applied on 3/23/2010) that will cause its grandfathered status to end.
___ Plan sponsor certifies that its group health plan is either not a grandfathered health plan, or if
currently grandfathered, does not wish to maintain its grandfathered status.
Name of Plan Sponsor: _________________________________________________________________
Group Policy No.: _____________________________________________________________________
Print Name:__________________________________________________________________________
Title: _______________________________________________________________________________
Signature:_____________________________________________Date:___________, 2012
Please Note: If you have multiple group policies with UnitedHealthcare, you should receive a
corresponding number of grandfather certification forms and cover letters. You must complete a
certification form for each policy that is grandfathered and you wish to remain that way.
Summary of Plan Changes Causing Loss of
Grandfathered Status
Under the federal grandfather rules, any one or more of the changes summarized below occurring after
3/23/2010 will end the grandfathered status of a group health plan and require full compliance with
PPACA. These rules may be applied separately to each benefit package offered under a group health plan.
The rules apply to pharmacy benefits as well as medical benefits provided under the group health plan.
1. Elimination of all or substantially all benefits to diagnose or treat a particular condition that applied on
2. Any increase in a percentage cost-sharing requirement, such as coinsurance percentage, that applied on
3. Any increase in a fixed-dollar cost-sharing requirement other than a copayment (such as a deductible
or out-of-pocket limit), if the total percentage increase measured from 3/23/2010 is greater than the
medical inflation percentage increase since March 2010, plus 15 percentage points;
4. Any increase in a fixed-amount copayment, if the total increase in the co-payment measured from
3/23/2010 exceeds the greater of: (1) $5 increased by medical inflation since March 2010; or (2)
medical inflation since March 2010, expressed as a percentage, plus 15 percentage points;
5. The Employer's decrease in its premium contribution rate, towards the total premium cost of any tier of
coverage by more than 5% below the contribution rate that applied on 3/23/2010;
6. Any addition of an annual dollar limit on all benefits, if there was no annual or lifetime dollar limit on
all benefits on 3/23/2010;
7. Any decrease in an annual dollar limit for all benefits that applied on 3/23/2010;
8. For any health plan that imposed a lifetime limit on all benefits, but no annual limit on all benefits on
3/23/2010, the addition of an overall annual dollar limit on all benefits that is lower than the lifetime
dollar limit on all benefits that applied on 3/23/2010;
9. Any change in insurance company providing the health insurance coverage or issuance of a new group
policy or certificate of insurance, with a coverage effective date after 3/23/2010 and before 11/15/2010;
10. The plan sponsor's transfer of employees from a grandfathered plan, without a bona fide
employment-based reason (not including cost of coverage), to another plan that was also
grandfathered, which, upon comparing the coverage terms of the plans or packages, results in any
change that would cause loss of grandfathered status.
Note: Special rules apply to fully insured, collectively bargained plans maintained under CBA(s) in
effect on 3/23/2010. These plans remain grandfathered at least until the expiration date of the last of
those CBA(s). On that expiration date, any plan changes made since 3/23/2010 are reviewed under the
grandfather rules, and if a non-permitted change was made, the plan will lose its grandfather status. The
only change allowed before the end of the last CBA, that will not negate grandfather status later, is a
change of insurer or entering into a new group policy or certificate between 3/23/10 and 11/15/2010.
The federal rules (published 6/17/2010), which include examples to illustrate their application, can be
found at the following Internet link:
We urge you to review these requirements with your legal advisor and benefit consultant in deciding
whether your group health plan is grandfathered and you wish to continue to maintain grandfathered
Summary of Administrative Requirements for
Maintaining Grandfathered Status
Group health plans that wish to be grandfathered are required to comply with the following
administrative requirements:
1. Provide a disclosure notice to their participants of the plan's grandfathered status in plan materials. (A
model notice is provided in the federal guidance, and is included below); and
2. Keep the records necessary to prove they have not made any of the changes since 3/23/2010 that
would cause that status to end, and provide them on request to participants and/or regulatory agencies.
Model Language - Notice
The following language reflects the model notice set forth in the interim final rules:
"This group health plan believes this plan is a "grandfathered health plan" under the Patient Protection
and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a
grandfathered health plan can preserve certain basic health coverage that was already in effect when
that law was enacted. Being a grandfathered health plan means that your plan may not include certain
consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement
for the provision of preventive health services without any cost sharing. However, grandfathered health
plans must comply with certain other consumer protections in the Affordable Care Act, for example, the
elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed
to the plan administrator at [insert employer contact information]. [For ERISA plans, insert: You
may also contact the Employee Benefits Security Administration, U.S. Department of Labor at
1-866-444-3272 or This website has a table summarizing which
protections do and do not apply to grandfathered health plans.] [For non-Federal governmental
plans, insert: You may also contact the U.S. Department of Health and Human Services at]"
M51547 7/12 © 2012 United HealthCare Services, Inc.

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