Oakley Insurance Group provides insurance options for clients that are not on Medicare and do not quality for AHCCCS/Medicaid assistance.
Health insurance is designed to cover two major causes: accident coverage, and sickness coverage. An accident is unintentional bodily injury caused by an unforeseen event, like a car accident, or falling out of a tree. Sickness is a need for medical care due to exposure to contagious illnesses, and in some cases hereditary disease.
The introduction of the Affordable Care Act (ACA) changed the face of health insurance largely for the betterment of the general population as compared to how health insurance previously existed. The ACA sought to end ongoing issues such as disqualification due to preexisting conditions, or children who while in College couldn't remain on their parent's health insurance. More about the ACA below, but you can visit the following link to begin the enrollment process. Using the link synchronizes your information with our database so if you should need assistance with your application, or in the future after you've enrolled, our agency will have access to your plan and information. Begin by CLICKING HERE
More About The Affordable Care Act (ACA)
De-Privatizing Insurance
The affordable care act de-privatized health insurance no longer allowing insurance companies to control many aspects of healthcare, aiming to shift health insurance from profit focused to patient focused - generally speaking.
Eliminating Preexisting Conditions
One of the most important changes was the removal of "preexisting conditions." Prior to the Affordable Care Act many people were left without insurance and therefore left without treatment and/or with unmanageable Medical debt.
Dependent Age Extension
The ACA also extended the age that dependents can remain on their parent's insurance plan while they remain in the household or remain dependents out of the house but in college.
Annual and Lifetime Maximums
The ACA no longer allows insurance companies to limit the amount of coverage they pay out for healthcare, regardless of the cost of medically necessary treatment. Before the Affordable Care Act, insurance companies could limit the amount of coverage allowed per year and per "lifetime" - lifetime meaning they will only pay up to a certain amount during your existence on earth, and once that amount was reached they would no longer provide coverage.
Created Affordability
The ACA off-sets patient monthly premiums based on incoming, allowing access to coverage by millions more Americans. In addition to premium off-set, the affordable care act also allowed those below a certain income threshold to have reduced copays, maximum out of pocket limits, and smaller or no deductibles.
Focus on Prevention
The Affordable Care Act aims to shift the focus of healthcare from being reactive (focusing on treatment) to being proactive by focusing on preventing illness. Through this effort most preventative measures such as annual physicals with blood work, mammograms, colonoscopies, and many other similar tests cost nothing. There is a list of no-cost preventative measures for general adults, women, and adolescents.
Additional Adolescent Inclusion
The ACA requires all plans to include dental and vision coverage for anyone under the age of eighteen.
As part of the ACA’s essential health benefits, when an emergency occurs no pre-authorization is required, or can be required by insurers regardless of the facility used for emergency treatment.
Prescription Drug Coverage
The Affordable Care Act requires each company offering a health insurance plan to offer prescription coverage for a minimum number of drugs in each category - such as blood pleasure medication, or antibiotics, etc. This ensures that medically necessary perceptions of nearly all categories are covered, usually with a co-pay but many Tier 1 generic prescriptions are zero-cost. Certain non-medically necessary prescriptions are not required to be covered, or the off-label use normally covered prescriptions may not require coverage. An example may be certain acne treatment drugs.
Included Services
This is not an exhaustive list of included services, but this list includes many of the major services part of the the ACA coverage that most of us may need at some point.
Why It's Called "Marketplace"
The health insurance marketplace replaced the old system that required each individual person to contact separate insurance carriers themselves. Now in one place, individuals can see all the available plans in their county, view offered premium assistance, choose a plan, and verify their doctors and medications are covered by certain plans.
This portion of the Affordable Care Act is probably the most debated, but there is a reason. We'll start with what the enrollment period is, then explain why it exists.
With the creation of the ACA, an annual enrollment period was formed called “Open Enrollment.” The Open Enrollment period is from November 1st to December 31st. To enroll or purchase a health insurance plan you may only do so during the open enrollment period. It is during this time that health insurance policies are updated, introduced, changed, or removed by insuring companies. This is also the time when you will review your household information (such as income) and choose your health plan for the upcoming year.
Under certain conditions a special enrollment period (SEP) may allow enrollment or change of a plan outside of open enrollment. An SEP can be triggered by things such as moving to a new zip code, marriage, significant change of income, loss of qualifying coverage, and the birth of a child. While those are examples SEP's can vary based on each individual situation - it is best to consult one of our agents regarding your situation.
Most people don't understand why there's an enrollment period. The enrollment period aims to help insurance remain stable by not allowing members to enroll in insurance, use it, then disenroll. Insurance relies on the law of large numbers which requires everyone to pay their premiums throughout the year while money is being moved to pay for covered services. If there wasn't an enrollment period, many people would abuse the system and only pay for the month or months they needed it, and not pay for the months they didn't which would cause a collapse in the current system.
When looking at healthcare coverage, there are a few terms you will see a lot, and here we will define those for you.
Maximum Out-of-Pocket (Max Out of Pocket (MOOP)): Every health plan has a stop-loss feature referred to as the maximum out-of-pocket cost. This means the amount listed as your max out-of-pocket will be the most you will have to spend out-of-pocket for medical care. Once that MOOP has been met, you do not have to pay anything out-of-pocket for covered medical care for the rest of the policy period, with the exception of pharmaceuticals the MOOP does not apply to prescription drug coverage. The MOOP will reset every year, and usually changes each year.
Deductible: A deductible is an amount of money you are responsible for paying before your policy pays anything for certain covered services. Preventative services are covered before your deductible is met. There can be a separate deductible for your medical care, and separate one for prescription drug coverage.
Depending on the deductible and the cost of service, out-of-pocket expenses may occur for the first few events. As an example, if you need to get stiches for a cut that will cost $1,700, and you have a $600 deductible, then you will pay $600, and your medical plan will pay the remaining $1,100.
Another example is, if the policy deductible is $2,500 and services are only $1,200, then the deductible hasn’t been met, so the full $1,200 must be paid out of pocket. The good news is, once you’ve paid the $1,200, the amount left to meet the deductible is reduced by $1,200, leaving $1,300 left in out-of-pocket expenses before the plan begins to pay. Once the policy deductible has been met, you will not need to meet the plan deductible until next policy year. Deductibles often work together with coinsurance, and copayments - more about that in those sections.
Low, to no cost plans with very high deductibles are called catastrophic plans, and are designed to cover catastrophic medical costs such as expensive emergency care, procedures, and hospitalization. These plans often have deductibles into the thousands of dollars.
Coinsurance: Co-insurance is a cost sharing method. Depending on your plan, the co-insurance amount may appear as: 70%/30%, 80%/20%, or 90%/10%. The first number (higher number) is the percentage of the medical cost the insuring company will pay, and the second number (lower number) is the percentage you will pay. These co-insurance amounts are usually used for potentially high-cost services or products such as blood laboratory work, emergency services, and expensive specialty brand pharmaceuticals. Here’s an example of how co-insurance works. An emergency room visit costs $5,723, and your plan has an 80/20 co-insurance amount. You will pay 20% of the cost, which would be $1,144.60, and the insuring company would pay 80%, which is an amount of $4,578.40.
Deductibles and coinsurance limits can also exist for the same procedure. Using the example above, lets say your plan has a $1,000 deductible, and an 80/20 coinsurance after the deductible is met. This means you must meet the deductible first, before the coinsurance method applies. For an emergency visit of $5,723, the first $1,000 (your deductible) will be your responsibility leaving $4,723 for you and insurance to split = $944.60 for you, and $3,778.40 for the insurance. The total you would pay out is $1,944.60. Remember, any amount you pay out of pocket goes toward your maximum out of pocket limit discussed above.
Copay: A copayment is a predetermined amount you pay to your provider or pharmacy for services or products rendered. You pay the co-pay amount, and the plan pays the rest for the product or service. Any copayments do not apply to any policy deductibles, but they do apply to your maximum out of pocket. Once you've hit your maximum out of pocket for the calendar year, you will not pay any more copayments until the next year.
