Last reviewed: 7 October 2026

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Health plan protections under the ACA: pre-existing conditions, cancellation, dollar limits and coverage to age 26, and what grandfathered plans keep

The short answer: federal law bars health plans and insurers from imposing a pre-existing condition exclusion, from setting lifetime or annual dollar limits on essential health benefits, from rescinding coverage except for fraud or an intentional misrepresentation of material fact, and from ending dependent coverage of a child before age 26 where the plan offers dependent coverage.^[1][2][3][4] A "grandfathered" plan, meaning coverage in which someone was enrolled on March 23, 2010, keeps some of these protections and not others, and the rule treats individual-market and group coverage differently.^[5] This page sets the rules out side by side. It does not rate any plan.

The short version

• Section 2704 (42 U.S.C. 300gg-3): a plan or issuer "may not impose any preexisting condition exclusion" with respect to the plan or coverage.^[1]
• Section 2711 (300gg-11): no lifetime limits, and generally no annual limits, on the dollar value of benefits.^[2]
• Section 2712 (300gg-12): no rescission once you are covered, except for fraud or an intentional misrepresentation of material fact.^[3]
• Section 2714 (300gg-14): a plan that offers dependent coverage of children must keep it available until the child turns 26.^[4]
• Grandfathered plans: 45 CFR 147.140 says which of these apply to them. The answer depends on the protection and on whether the coverage is individual or group.^[5]

Which protections apply to which plans

Pre-existing conditions

• The statute defines a pre-existing condition exclusion as a limitation or exclusion of benefits for a condition based on the fact that it was present before the date of enrollment, whether or not any medical advice, diagnosis, care or treatment was recommended or received.^[1]
• The regulation gives two examples. A new policy that excludes oral surgery needed after a traumatic injury, if the injury happened before the coverage began, is a prohibited exclusion. A denial of an individual-market application because an exam revealed type 2 diabetes is treated as one too.^[6]
• HealthCare.gov says no plan can reject you, charge you more or refuse to pay for essential health benefits for a condition you had before your coverage started, and that grandfathered plans do not have to cover pre-existing conditions. That statement is about individual policies; 45 CFR 147.140, in the table above, applies the prohibition to grandfathered group plans.^[10][5]

Dollar limits

• The rule bars lifetime and annual limits on the dollar amount of essential health benefits, in network or out of network. A health flexible spending arrangement offered through a cafeteria plan is exempt from the annual-limit rule.^[7]
• It does not stop a plan from placing annual or lifetime dollar limits on specific covered benefits that are not essential health benefits, to the extent other federal or state law allows. It also does not stop a plan from excluding all benefits for a condition; but if any benefits are provided for a condition, the limit rules apply.^[7]

Cancellation and rescission

• The regulation defines a rescission as a cancellation or discontinuance of coverage that has retroactive effect. Coverage may be rescinded only if the person, or someone seeking coverage for them, performs an act, practice or omission that constitutes fraud, or makes an intentional misrepresentation of material fact, as prohibited by the plan's terms. The plan must give at least 30 days' advance written notice. The rule says this applies regardless of any contestability period.^[8]
• It lists what is not a rescission: a cancellation with only prospective effect; a retroactive cancellation attributable to failure to pay premiums on time; one the individual initiates, if the plan does not influence or retaliate; and one initiated by the Exchange under 45 CFR 155.430, with a stated exception.^[8]
• The rule's example: a person who inadvertently omitted two psychologist visits from six years earlier on a questionnaire, and is then diagnosed with cancer, cannot have coverage rescinded, because the omission was not fraud or an intentional misrepresentation.^[8]

Coverage for children to age 26

• The rule says a plan or issuer that makes dependent coverage of children available must make it available until the child turns 26. Its example shows a plan covering a child through the day before the 26th birthday as satisfying it.^[9]
• For a child under 26, a plan may not deny or restrict dependent coverage based on financial dependency, residency, whether the child lives or works in the network area, marital status, student status, employment, eligibility for other coverage, or any combination.^[9]
• A plan need not cover a child of a child receiving dependent coverage. It may limit coverage to children as defined in section 152(f)(1) of the tax code, and for someone not described there, such as a grandchild or niece, may add conditions such as being a tax dependent. The terms of dependent coverage of a child under 26 cannot vary based on age, though age-based distinctions that apply to everyone covered under the plan are not a violation; a surcharge for children older than 18 is the rule's example of a violation.^[9]
• HealthCare.gov says that for a Marketplace plan you can stay on a parent's plan through December 31 of the year you turn 26, or the age your state permits, and that for a job-based plan you can generally stay until you turn 26 even if you marry, have a child, leave school or live elsewhere. It tells you to check with the plan or employer about staying after 26, because some states and plans differ.^[11]

What "grandfathered" means

The regulation defines grandfathered health plan coverage as coverage provided by a group health plan, or a group or individual health insurer, in which an individual was enrolled on March 23, 2010, for as long as it maintains that status under the rule. To keep it, the plan must say in its summary of benefits that it believes it is grandfathered and give contact information for questions and complaints.^[5] HealthCare.gov describes a grandfathered plan in the individual market as a policy purchased on or before March 23, 2010, not sold through the Marketplace.^[10]

How to verify this yourself

Read the five statutes and rules in the references, in particular 45 CFR 147.140(c) to (e) for the grandfathered-plan table, then check your own summary of benefits.

What this page does not cover

We do not cover Medicare, Medicaid, short-term or other excepted benefits, state-law protections, the list of essential health benefits, how any individual claim should be decided, or the other sections of 45 CFR part 147. We do not say whether any plan complies. This is general information, not insurance, tax or legal advice. For your own situation, ask your agent or insurer, or contact your state or provincial insurance regulator.

Your next step

A grandfathered plan must say so in its summary of benefits. The table above shows which protections such coverage keeps, and a state insurance department can say whether state-law protections apply on top.

Related checks

Our standard explains how we check an agent's license and disciplinary history. Check an agent reports our findings at category level, as a method and not a verdict. Neither reviews any insurer, plan or product. See also the Summary of Benefits and Coverage, which is where a grandfathered plan must say so, and metal tiers. More plain-language guides are in the agent guides.

When we will update this page

We re-read the sources when they change. If something here is out of date, tell us. Corrections are dated on the page.

References

1. [1] Cornell Law School Legal Information Institute, text of 42 U.S.C. § 300gg-3 (prohibition of preexisting condition exclusions), read 7 October 2026 — law.cornell.edu/uscode/text/42/300gg-3
2. [2] Cornell Law School Legal Information Institute, text of 42 U.S.C. § 300gg-11 (no lifetime or annual limits), read 7 October 2026 — law.cornell.edu/uscode/text/42/300gg-11
3. [3] Cornell Law School Legal Information Institute, text of 42 U.S.C. § 300gg-12 (prohibition on rescissions), read 7 October 2026 — law.cornell.edu/uscode/text/42/300gg-12
4. [4] Cornell Law School Legal Information Institute, text of 42 U.S.C. § 300gg-14 (extension of dependent coverage), read 7 October 2026 — law.cornell.edu/uscode/text/42/300gg-14
5. [5] Electronic Code of Federal Regulations, 45 CFR § 147.140 (preservation of right to maintain existing coverage), read 7 October 2026 — ecfr.gov/current/title-45/section-147.140
6. [6] Electronic Code of Federal Regulations, 45 CFR § 147.108 (prohibition of preexisting condition exclusions), read 7 October 2026 — ecfr.gov/current/title-45/section-147.108
7. [7] Electronic Code of Federal Regulations, 45 CFR § 147.126 (no lifetime or annual limits), read 7 October 2026 — ecfr.gov/current/title-45/section-147.126
8. [8] Electronic Code of Federal Regulations, 45 CFR § 147.128 (rules regarding rescissions), read 7 October 2026 — ecfr.gov/current/title-45/section-147.128
9. [9] Electronic Code of Federal Regulations, 45 CFR § 147.120 (eligibility of children until at least age 26), read 7 October 2026 — ecfr.gov/current/title-45/section-147.120
10. [10] HealthCare.gov, "Coverage for pre-existing conditions", read 7 October 2026 — healthcare.gov/coverage/pre-existing-conditions/
11. [11] HealthCare.gov, "How to get or stay on a parent's plan", read 7 October 2026 — healthcare.gov/young-adults/children-under-26/