Michelle Katz Celebrity Guru

A healthcare consultant and international medical reporter, Michelle Katz, M.S.N., is the host of Today's Health and has appeared on many healthcare radio and television shows across the country, including Voice of America where she was nominated for a piece she produced on the psychological and physiological effects on orphans of parents with AIDS in Africa. A past senior healthcare consultant at Arthur Andersen and now founder and President of HCStrategies, Michelle has consulted on many healthcare issues from quality assurance to billing and procedural coding. More recently, she was involved in the development of congressional healthcare legislation. She received her master's degree in nursing from Georgetown University after recovering from a severe car accident when she did not have health insurance and navigating her way through the healthcare system -- with minimal bills in the end. She currently lives in Washington, DC and gives lectures on saving money in healthcare and educates others on Medicare and other aspects of healthcare.

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Is an HMO the right plan for me?

A Health Maintenance Organization, or HMO, is a type of group health insurance plan. This is the most common type of health insurance, and most health insurance companies provide an HMO option--even Medicare. It also tends to be the least expensive kind of health insurance, the least flexible and requires that you select a Primary Care Physician (PCP) and obtain pre-authorizations for certain medical procedures as well as referrals to see specialists.

So before you run out and sign up for an HMO, please keep the following points in mind about HMOs:

• They do not require claim forms for office visits or hospital stays.
• They focus on prevention.
• With most HMOs, you must stay in your network of doctors and medical facilities.
• You may have to wait longer for an appointment than some other forms of insurance.
• They charge a fixed fee for your health care.
• There may be a small co-payment for each office visit
• It can be difficult to get specialized care, and extremely expensive if you go outside the network for that care.
• Situations covered as emergency care are strictly limited.
• There may be a high turn-over rate among providers.

Your local state Insurance Department can help provide you with a list of HMOs in your area as well as general background information on which health care services are covered www.naic.org/state_web_map.htm.
So if you are looking for the least expensive, simple policy, and rarely see your physician, this may be the policy for you; however, if you have unusual medical needs, there may be a better option.

Who is Eligible for COBRA?

Generally, there are three groups of people who are eligible for COBRA coverage: employees or former employees in a private business with at least 20 employees, their spouses, and their dependent children. One of several types of "qualifying events" must occur in order to trigger COBRA, such as:
• job termination
• reduced hours
• employee entitled to Medicare
• death of employee
• divorce or legal separation
• loss of dependent-child status
• bankruptcy of employer

Can COBRA Coverage Work for You?

COBRA may be a good option for people who have "pre-existing conditions", as it allows you to continue your already existing coverage while you look for other options without there being a gap in coverage. When ever there is a gap in coverage, you run the risk of being denied insurance or paying increased premiums the next time you sign up for health insurance.

In order to continue healthcare coverage with COBRA, you must follow certain guidelines in order to avoid a potential drop in coverage.
• Both you and your employer must follow proper procedure to initiate COBRA, or else you could forfeit your rights to coverage.
• The employer must notify the health plan administrator (typically, the employer; or
the person in which you mail your premium payments to) within 30 days after an employee's death, job termination, reduced hours of employment, or eligibility for Medicare.
• In cases of divorce, legal marital separation, or a child's loss of dependent status, it is your (or your family's) responsibility to notify the health plan administrator within 60 days.
• The plan administrator has 14 days to alert you and your family members—in person or by first-class mail—about your rights to COBRA. If the plan administrator fails to act, he or she can be held personally liable by the IRS for a breach of duties.

What is the COBRA Coverage?

Your COBRA coverage can last from 18 months (for losing your job) to 36 months (for a divorcee). At any time during this period, you can choose to obtain another type of healthcare coverage.

COBRA eligibility is extended to workers in state and local government, as well as to independent contractors. This law excludes the District of Columbia, all federal employees, certain church-related organizations, and firms employing fewer than 20 people (however employers must include their part-time workers to determine if they are exempt).

If you work at a small company that is exempt from federal law, you are not completely out of luck. Many states have adopted their own laws, sometimes known as "mini-COBRA," that often grant broader rights to determine your eligibility for coverage (check with your state insurance department).

If you are applying for COBRA under job termination, this includes voluntarily resignation from a job or termination—for any reason except "gross misconduct."

If you elect COBRA continuation coverage when you are working, i.e. when you decide to accept your former job’s healthcare plan instead of your new employment, you can keep your health coverage, but you must pay the full premium. In some states, Medicaid helps pay for the premium. Contact the Department of Labor (DOL) at 1-866-444-3272, or access DOL's website at www.dol.gov

Advantages of Preferred Provider Organizations (PPOs)

In general, PPO insurance combines the lower cost of managed care with the greater degree of choice found in traditional health insurance. Similar to an HMO, you will pay a fixed monthly premium. In return, the health insurance company and its health care network provide basic medical benefits to you.
Advantages:

• health care costs are relatively low when using the PPO networks
• you can consult any specialist, including ones outside the plan
• seeing a primary care physician is not a prerequisite

Disadvantages of Preferred Provider Organizations (PPOs)

Disadvantages
• paperwork is your responsibility if the care is non-network
• out-of-pocket costs per year are limited
• cost of treatment outside of network is more expensive
• co-payments are larger than with other managed care plans
• you may need to satisfy a deductible
When you are out of the network, you will be responsible for a deductible before your PPO begins contributing. After your deductible is met, you will still be required to pay a percentage of the cost, and this percentage will be higher than if you had stayed in the network. You may also be required to pay the difference between what your out-of-network doctor charges and what your plan deems to be "reasonable and customary" for the service.

Is a PPO Right For Me?

If you are struggling with how to evaluate the quality of your PPO plan or want to know how an HMO compared to a PPO does service wise, use the list of questions below as a guide. Again, if, for any reason, the health insurance policy does not answer to your satisfaction, be hesitant about purchasing it.
• How many doctors are there to choose from?
• Are doctors in the network private or group practice physicians?
• Where are the offices and hospitals in the network located?
• How are referrals to specialists handled?
• What hospitals are available through the plan?
• What arrangements does the plan have for emergency care?
• What health care services are covered?
• What preventive health care services are covered?
• Are there limits on medical treatments or other services?
• How much is the health insurance premium?
• Is there an out of pocket maximum?
• Is there a cap on services?
• Is there a financial cap?
• What, if any, are the co-payments for specific services?
• How much more will it cost to use non-network physicians?
• What is the deductible and co-insurance for non-network care?
You should definitely discover what is required, what may be required, what financial considerations exist, and which health insurance options are best suited for all of these questions before purchasing a plan.