The past several years have brought tremendous changes the way health care is delivered. Regardless of your politics, we can agree the Affordable Care Act (aka Obamacare) has accelerated these changes and brought many new ones.

As a physician, I witness firsthand the frustration that patients deal with, and I have written this short piece as a primer regarding some of the concepts and terms you need as a patient to understand to navigate our health care world.

The Affordable Care Act is an expansive law passed in 2010 that was intended to reduce the cost of health care and increase quality. Some of the major changes include:

A penalty for being uninsured, which is assessed on your yearly tax return.

An expansion of Medicaid to increase the number of people who are eligible. Some states have not elected to participate in the expansion and Texas is one of them.

Health care exchange that allow people to shop for individual health care plans on the open market. Depending on your state, the programs are administered through a federal or state exchange (Texans use a federal exchange).

Quality initiatives change in the way doctors and hospitals get paid by Medicare, as well as new requirements for doctors and hospitals requiring the use of electronic medical records. Also included are new government set quality metrics that must be met.

Out of pocket/deductible is the portion of health care costs that you are responsible for in a given year. For example, if you have a $6,000 out-of-pocket responsibility/deductible with your insurance, and you need a surgery that is $10,000, you will be responsible for $6,000 and the insurance company for $4,000. Once you have met your yearly deductible, the insurance company is responsible for 100 percent of eligible services (minus co-insurance). Out-of-pocket costs typically come into play for surgeries, lab tests, X-rays and hospitalizations. If you have a family health care plan, you may have a separate individual and family out-of-pocket threshold.

Copay is the portion of doctor visit that you are responsible for. Many insurance plans will have a designated copay for visits to a doctor's office and another for emergency room visits or urgent care. There may be different deductibles for primary care (your main doctor) versus specialists. Your insurance plan will cover the remainder of the visit (as long as it is a covered benefit). Some insurers now include a pharmacy deductible. You may have to meet a pharmacy deductible before your medications are covered.

Coinsurance is similar, but it applies to services rendered (surgery, hospitalization, etc.) and applies after the deductible is met. It is a percentage, not a fixed amount.

Insurers require what's called prior authorization before paying for certain medications and procedures. This means that before paying, the insurer must pre-authorize the drug or procedure. When your doctor wants to prescribe certain medicines or perform certain procedures, the doctor's office has to fill out the required paperwork and submit it to the insurer for approval. Insurers are the ultimate authority as to whether you need the recommend medicine or procedure, not the doctor.

Dr. Jason Acevedo is a board certified ear, nose and throat doctor at South Abilene Ear, Nose and Throat.

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