Should Medicare Agents Sell PPO or HMO?

Hey what's going on everybody kenny lammons here with medicare millennials uh where of course we chronicle our journey to building a large successful medicare book of business and take you guys along for the ride try to help answer your questions and provide a little bit of guidance for how this journey is going for us so it can.

Translate to you and today as medicare annual enrollment period rapidly approaches i've been getting more and more questions on should i focus on selling hmos or ppos when i'm doing a medicare advantage presentation and that's a very good question and if you're new i completely understand why.

You would ask that question but i'd like to shed a little bit of light on why it's that's not maybe the right way to ask the question okay so this is gonna be really good not only for newer agents but maybe for agents who are expanding into the medicare advantage uh plan market and you're used to.

Only selling medicare supplements where you would never even think to ask a question like that okay so first of all let's just break down real briefly what's just the and don't this may not be the webster or cms dictionary version of of what these two things mean but let me just.

Explain in in layman's terms the difference between an hmo and a ppu so with an hmo that stands for health maintenance organization and you're going to have a more constricted network and that network is you don't have in and out of network benefits typically speaking.

In an hmo you've got to stay within a defined network now on medicare advantage plans those hmos are going to provide coverage for emergency situations but for any general routine care that is not urgent or an emergency you have to stay in network or it will not pay for that care in any way.

Okay so you also typically must select a primary care physician and you typically need to get a referral if you want to go see a specialist okay so just think about that that's a tight knit group of health providers you're gonna go through your primary care doctor first and you're gonna get referrals before you go.

Marching off to see a bunch of different specialists or or get different specialized tests done okay so it's a bit more restrictive in that way and we'll that may sound like a con but let me just define to find it that way for a moment we'll come back to it then we have a ppo okay which is a.

Preferred provider organization and what a ppo is is you have both in-network and out-of-network benefits okay but you're going to get if you go with the preferred or the in network providers you're going to get preferred pricing your copays are typically lower your max out of pocket.

Is lower maybe there's no deductible in network but there may be one out of network but if you are traveling or routinely going somewhere outside of network you do still have benefits and coverage outside of that network now obviously if you're not planning to stay.

In network you might need to that's going to impact your decisions you don't always want to be paying out of network co-pays or not out of network max out-of-pocket so but a ppo you don't necessarily have to select a primary care physician and you don't necessarily need to get.

Referrals to go see a doctor whether they're in or out of network you don't need a referral typically so that's the general difference between the two and they both have their pros and cons but the question that i posed at the beginning was should i focus on selling hmos or ppos and there.

Are a lot of agents out there that'll swear by one or the other and they'll you know pretty much maybe never offer the the alternative and that's a big mistake guys there's just so many varying needs out there so the best way i can answer it is this this has just been my experience if somebody has been seeing the same.

Primary care doctor and has an a super good relationship with like a specific network of doctors or maybe a specific provider network in their local area and they've been using them and trust them especially the primary care doc for a number of years then a lot of time in hmo can be really beneficial to them.

Because you'll often hear people say i don't care if i have to get a referral i always go where my doctor recommends anyway so they're used to kind of they're never going to try to go pick a doctor on their own they're always going to go through that network of providers specifically that.

Primary care doctor so for that type of person if they're willing to work within the confines of that hmo and get those referrals and stay in network almost always what we see is that an hmo especially when it comes to medicare advantage plans has the benefit to that is there's often.

Lower co-pays lower max out of pockets zero dollar monthly premiums or at least low monthly premiums and oftentimes some really good rich extra benefits to go along with your plan that they might not offer on their ppo such as maybe some better dental benefit.

Hearing benefits transportation among other things so it's simple if you're well it's not always this simple but the simple answer is you've got to fit it to their needs if they have no issue with the referral they do not travel they would never use a provider.

Outside of the network unless it was an emergency and they're very cost sensitive and price sensitive and there may be low income not quite on medicaid but they're low income then and they're interested in those additional benefits like all of those things right so they they don't have a problem being confined.

To that network they are very price sensitive they're interested in those any additional benefits or extra help that they can get then an hmo may be great for them alternatively if somebody does travel more frequently or they just because you can simply ask.

Does it bother you to get a referral you know is it common that you would ever go out of network or would you only work with your primary care doctor and a lot of times people are like no i do not want to go through the hassle of having to get a referral all it does is slow.

Slow things down make things more difficult and they're then they're aware that their co-pays may be a little bit higher especially if they go out of network then the ppo may be the better option for them so what do they value do they value flexibility right and this is where a needs.

Assessment a genuine conversation with your prospect happens or do they value above all else just having the lowest co-pays the lowest premiums and the most extra benefits and then you've got to help them navigate how ppo provides the flexibility but in hmo if they're willing to work within the uh.

That network often provides the lowest cost so none of this is hard and fast there's always one-off situations but if you're new to exploring the medicare advantage market it's not so straightforward and simple as the medicare supplement market as far as which doctors and providers you can see so i hope this is helpful to.

You guys just from a a high level overview of should you need to just understand what hmo and ppo what the differences are and how that one is is not always better than the other but it may be better for your client specific situation hope that was helpful guys you guys have.

A wonderful last few days before things get crazy on the 15th and we will talk to you soon

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