If you need coverage for one or more of your children, or if you've used the Blue Cross Blue Shield "Blue Pathway" in the past, read on to find out what's changing in child-only coverage here in Texas.
The Affordable Care Act (ACA) will bring back an important coverage option for Texas families: child-only coverage. Four of the five major carriers in the Texas market have not offered child-only coverage since October 2010, when "guaranteed issue" requirements under ACA were mandated. The introduction of 'guaranteed issue' meant that applications could not be denied for children 18 and under, regardless of health history or current health condition, and there was no waiting period for preexisting conditions. All of a sudden, the carriers (with the exception of Blue Cross Blue Shield) withdrew from the child-only insurance market in Texas because they feared without enrollment deadlines they would lose money by offering it, because parents would delay coverage until it was absolutely needed.
Blue Cross Blue Shield continued to offer a child-only plan known as Blue Pathway that provided only one plan option and had a limited enrollment period each year from May 1st to June 30th. Blue Cross Blue Shield required that open enrollment period to protect against families waiting until their child got sick before securing coverage - something called 'adverse selection.' Adverse selection creates an environment where only unhealthy individuals secure coverage, which means there are no 'healthy premium dollars' to offset the 'unhealthy premium dollars.' When that happens, suddenly all premiums skyrocket to cover the huge claims expense. The implementation of an enrollment period requires all individuals seeking health insurance to make their coverage decisions at the same time. If you needed health insurance for a child outside of the Blue Pathway enrollment period - for example, if you gave birth to a new child in the fall - your only option was either an employer-sponsored group plan or a short-term policy.
Now, ACA mandates that carriers make available child-only plans. During the Initial Open Enrollment period from October 1, 2013 to March 31, 2014, parents will be able to select coverage from one of the four metallic plan options offered by the marketplaces - platinum, gold, silver, or bronze. All plans will include the required essential health benefits with preventative care services paid by the carrier at 100% with no deductible. Other essential health benefits that everyone will (and must) receive include prescription benefits and pediatric services, including vision and dental care.
Prescription benefits will no longer exclude prescriptions related to attention deficit or hyperactivity, which in the past were sometimes excluded. The coverage beginning January 1, 2014 will provide benefits for children with no exclusions for preexisting conditions and no waiting period for benefits.
As a parent, should you get child-only coverage from the general marketplace, or from your employer? In the past, coverage offered by an employer often provided more comprehensive benefits compared to plans you might find if you searched online for options available in the individual market. However, with the reforms provided by ACA, coverage in the individual market is now just as robust as coverage offered by employers. In fact, Texas parents may discover that the benefits available from the marketplaces are actually stronger than coverage offered by the employer for this main reason: as an employee, you cannot be charged more than 9.5% of your income for your employer-provided group premium. In order to meet this cost requirement under ACA, employers may be forced to scale down the benefits they offer you.
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