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Exit Survey »
 
 
Grandfathered Status Survey


SRC will renew and administer your plan(s) based on your grandfathered status, which must be recorded annually prior to plan renewal.

If you answer “Yes” to any of the following questions, then your plan will not be grandfathered. Invalidating changes made between March 23, 2010 and June 13, 2010 may be undone at your next policy renewal.

If you answer “No” to all of the questions, then SRC will record your status as “grandfathered” unless you notify us 45 days prior to your plan renewal date that you do not wish to retain grandfathered status. Please note that once grandfathered status is forfeited, it cannot be regained.

For the purpose of this survey, the questions should be answered as they relate to your limited benefits medical plan with SRC/Aetna only.
 
 
 
* Group ID number:
   
* Group name:
   
* Name of respondent:
   
 
 
Compared to your Aetna/SRC group limited benefit medical plan in effect on March 23, 2010, have you since made, or do you plan to make, any of the following changes?
Yes No
* 1. A decrease of more than 5% in your plan sponsor contribution to the coverage?
* 2. A change in insurance carriers?
* 3. Reclassified employees so that the reclassified employees are eligible for a different plan (even if it’s a grandfathered plan), without a bona fide employment reason?
 
 
Our records indicate that none of the following invalidating changes have been made to your plan.

However, if you believe any of these changes have been made, please indicate it by changing the value to “yes.”
Yes No
* 1. Reducing coverage limits or other benefits provided in the plan?
* 2. Increasing a member’s coinsurance percentage by any amount?
* 3. Increasing a member’s fixed-amount copayment above a specified level (defined as Medical Inflation expressed as a percentage, plus 15 percentage points)?
* 4. Increasing deductibles above a specified level (defined as Medical Inflation expressed as a percentage, plus 15 percentage points)?
* 5. Failing to continuously maintain at least one covered individual (not necessarily the same individual) during your plan year?
 
 
 
If your business has had any other changes that could potentially impact the status of your plan, please describe the nature of the change below, and contact your SRC Account Manager to discuss any potential impacts on your grandfathered status.
   
 
 
 
Since you answered “no” to all questions, we will record your status as “grandfathered” for the purpose of administering your Aetna/SRC group limited benefit medical plan upon renewal.

If you feel this status is incorrect for your plan, please contact your SRC Account Manager immediately.
 
I agree
 
I do not agree. I will contact my SRC Account Manager to discuss.
 
NOTE: This basic checklist survey does not list all of the actions that may invalidate grandfathered status. If you have concerns about your status, you may want to consult your benefits advisor or legal counsel. This information is subject to change and should not be construed as, nor is it intended to provide, legal or compliance advice.
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