How do you determine PPO or HMO for clients?

[jack3454]

I ask how often they travel and to where and if they dont mind getting referrals to specialists, but wondering if I should be digging deeper than this when determining if a HMO or PPO would be better for someone.

 

[straightnochaser]

I ask how often they travel and to where and if they dont mind getting referrals to specialists, but wondering if I should be digging deeper than this when determining if a HMO or PPO would be better for someone.

A lot of HMO's don't require referrals and have a national network.. I typically don't decide what is best for the client, I will let them make an educated (by me) decision.

 

[axeman462]

I ask how often they travel and to where and if they dont mind getting referrals to specialists, but wondering if I should be digging deeper than this when determining if a HMO or PPO would be better for someone.

as you are doing your warm-up/fact finding you need get a sense of what is important to them.

Often their preferred doctors and Rx will help dictate what direction to go in. But if it doesn't...

Look for things like cost, flexibility, prior-authorizations, referrals, networks, extra benefits etc..

if low cost is really important to the customer generally speaking start leaning toward an HMO.

If they want to deal with less prior-authorizations start leaning PPO. HMOs, generally speaking, require 2-3 times as many prior-authorizations for various services on average as compared to a typical PPO.

If they want more freebies, than lean back to an HMO. HMOs typically give away more stuff.

But most of all, Spend more time in your warm-up/fact finding stage of the sales cycle. Don't be afraid to get to know your customers a little more, they will tell you what their needs and fears are.

Sometimes, I even ask them if they have a preference of an HMO or PPO. If they don't know the difference, explain it to them.

 

[Limozine]

I explain the difference between an HMO and PPO, and point out that (usually) HMOs have stronger ancillary benefits in exchange for a more restrictive network, i.e., that there is almost always a trade-off of some kind. Then I let them tell me if the benefit is worth it.

 

[vic120]

I explain the difference between an HMO and PPO, and point out that (usually) HMOs have stronger ancillary benefits in exchange for a more restrictive network, i.e., that there is almost always a trade-off of some kind. Then I let them tell me if the benefit is worth it.

PPO gives you higher copays and less benefits for the illusion of more freedom

In most cases the only way they really benefit by have that extra out of network is if they get cancer and pay that huge out of pocket and just want to go there

Now there are exceptions like Devoted has PPO's where the out of network is the same as in network

but they are not everywhere and I have seen plans like that come and go before

But most PPO plans have a much higher out of network then in network, and the in network is not necessarily much bigger then the HMO

Most times if I find someone stuck on MAPD its because of budget, and they many times prefer the benefits of HMO but are scared because they heard HMOs are bad or was told they need a PPO

I found I have better retention with those IF I show them not to be afraid of the HMO if their docs are in network

Otherwise they fall victim to some TV commercial or whatnot

Now there is another type with higher incolme who will not prefer HMO for many of these same reasons but they do have a better understanding of the out of network costs

Yes with those I will usually start out with PPO though they may go HMO later but with me

But still these type more times than not
go med supp with me