The challenge with health insurance is that we hear about it once a year during open enrollment, and the next time we use it we are either not feeling well, or checking out at the pharmacy or doctor’s office. You’ve heard about the following terms, now you’ll know what they mean:

Copay – a preset amount you pay for a covered health care service, such as a doctor visit or prescription. You pay the set amount, your health plan pays the rest.

Deductible – an annual amount you’ll pay before your health plan begins to pay for certain covered services.

Coinsurance – your share of the cost of covered health care services after the deductible has been met. Your health plan pays the rest of the covered charges.

Out-of-Pocket Maximum – the most you’ll pay before your health plan begins to pay 100% of covered medical services. In many cases, your deductible, coinsurance, and copays counts towards your total out-of-pocket maximum. Check your health plan for details.

In-Network – health care facilities, doctors, and pharmacies that have contracts with your health insurance plan to deliver services at a negotiated rate or discount. You will typically have lower out-of-pocket costs for services you receive in-network.

Out-of-Network – a health care facility, doctor, or pharmacy that does not have a contract with your health insurance plan. They typically don’t provide services at a discounted rate and you will have higher out-of-pocket costs.

Primary Care Provider – also known as a PCP, this is your personal health care provider who coordinates all of your medical care, from routine physicals to referring you to specialists. This physician gets to know you, your medical history, and your personal preferences, which can be very valuable.

Pre-certification – pre-certification is getting approval from your health insurance plan before receiving services such as hospital stays, advanced testing, or outpatient procedures. During this process, your health insurance plan reviews medical criteria to determine coverage under your health insurance plan.

I often talk with clients about when to use different providers for medical care. “Should I go a Convenience Care Clinic, Urgent Care Clinic, the Emergency Room, or see my doctor?” is a question often asked in enrollment meetings. So I thought I’d give a handy primer.

But, as always, if it is a life threatening emergency dial 911!

Convenience Care Clinic – these clinics treat minor medical concerns. They are typically staffed by Nurse Practitioners and Physicians Assistants. Located in retail stores and pharmacies. Often open nights and weekends. Cost is typically lower than a doctor’s office, no appointment needed, and wait times are typically 15 minutes or less.

Conditions treated*

• Common Cold / Flu
• Rashes or skin conditions
• Sore throat, earache, sinus pain
• Minor cuts or burns

Doctor’s Office – the best place to go for routine or preventive care, to keep track of medications, or to see a medical specialist. May charge a co-pay or cost applies to your deductible, usually requires an appointment, short wait times.

Choosing the medication that’s right for you is up to you and your doctor. Most insurance companies can help by offering an extensive list of covered brand, generic, and specialty medications so you and your doctor can decide what’s best for you based on how well it works and how much it costs. Most drugs fall into one of four categories:

Generic Medications – Generic medications have the same active ingredients, dosage, and strength as their brand name counterparts. You will usually pay less for generic medications.

Preferred Brand Medications – Preferred brand medications will usually cost more than a generic, but may cost less than a non-preferred brand. When a generic drug is not available, choosing a preferred brand can be a lower cost option.

Non-preferred Brand Medications – Non-preferred brand medications generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for non-preferred medications.

Specialty Medications – Often more expensive medications, high technology medications and self-administered injectable medicine that are not available under preferred or non-preferred brand levels.

So how do you use your medical plan to get the most benefit?

On July 30, the Department of the Treasury and the Internal Revenue Service (IRS) issued a second notice regarding the 40% Excise Tax a.k.a. the Cadillac Tax. The notice provides information on possible approaches that are being considered for administering the Cadillac Tax and continues the process of gathering input that will be used to develop regulations.

This is a follow-up to the notice issued on February 23, 2015, and comments may be submitted until October 1, 2015.

The notice addresses several issues, including:

• Who pays the tax
• How the tax will be determined
• How the tax will be paid

Who Pays the Tax

Each “coverage provider” must pay the tax on its share of the excess benefit. A coverage provider is:

• The health insurer for insured coverage.
• The employer for accounts such as Health Savings Accounts (HSAs) to which the employer contributes.
• The plan benefits administrator – the agencies are seeking comments on whether this should be the third-party administrator or the entity that has ultimate responsibility for plan administration, typically the employer.

How the Tax will be Determined

The notice seeks comments on how to calculate and administer the tax. The following are some of the proposed approaches:

The Supreme Court released their ruling on King v. Burwell today. The vote was 6-3 in favor of upholding health premium subsidies in all States, including States that have a Health Plan Exchange run by the Federal Government.

Now that the decision is made, we will most likely see action in Congress to clean up parts of the Affordable Care Act.

Here is a link to the Supreme Court’s Opinion: http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf