The Affordable Care Act: Open Enrollment for Health Insurance Marketplaces is October 1, 2013

October 1, 2013

Blue Cross and Blue Shield of Texas (BCBSTX) shared information in the May 2013 issue of Blue Review about how we are helping to prepare our communities for change resulting from the Affordable Care Act (ACA). The amount of change can seem overwhelming to you and your patients, so it is helpful to understand the basics of the Health Insurance Marketplace open enrollment.

Health Insurance Marketplace Open Enrollment

Open enrollment for the new public Marketplace begins October 1, 2013, for individuals and small employers in the state of Texas. Individuals will need to have completed the enrollment process by Dec. 15, 2013, to begin receiving benefits on January 1, 2014. Individuals can continue to enroll for coverage in 2014 until March 31, 2014.

As we've done for more than 70 years, BCBSTX’s goal is to expand access to cost-effective health care to as many people as possible. Although we have not yet received final certification to market our products, BCBSTX intends to offer new products on the Health Insurance Marketplace beginning October 1, 2013. In fact, BCBSTX has entered into an agreement with the Centers for Medicare & Medicaid Services (CMS) to provide health insurance coverage through Qualified Health Plans on the Texas Health Insurance Marketplace.

If you are a participating provider in our Blue Choice PPO or our new Blue Advantage HMO network, you may see members who purchase coverage through the Health Insurance Marketplace or the Small Business Health Options Program (SHOP).

Essential Health Benefits

ACA requires all health plans in the Marketplace to cover ten categories of essential health benefits (EHBs). The EHB categories are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and rehabilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

Other ACA-Related Changes

In previous issues of the Blue Review, we've discussed many other ACA-related changes and initiatives that will affect provider practices, including:

  • Risk adjustment, reinsurance and risk corridor programs that are designed to promote premium stability in both individual and small group markets
  • Young adults may stay on a parent's policy until they turn age 26
  • Certain preventive services must be covered by some types of plans without cost-sharing (copay, coinsurance, or deductible) when using an in-network provider

Marketplace plans will be divided into four different levels — Bronze, Silver, Gold and Platinum. The key difference between these "metallic" plans is the percentage of covered medical expenses shared between the health plan and the member.

Private insurers in the individual and small group market will not be permitted to refuse coverage to anyone based on health status, including pre-existing conditions.

Over the coming months, we will be sharing additional information about the different aspects of health care reform that may affect you and your patients. Watch Blue Review, and please visit us at

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