- 619
Which one is best for the client PPO or PPFS is everthing else is equal ?
PPO or PFFS
- Thread starter Insuranceman
- Start date
- 7,066
If a Med Supp isn't an option then hands down the PPO is superior coverage if your prospect is concerned about the availability of quality health care.
- 1,183
Well, nothing in my experience is exactly equal e.g. premium, copays, coinsurance, etc.
When the premiums and benefits were in the same ballpark, when I was regularly selling these plans, I usually recommended the PPO (which was typically a little cheaper and in some cases had a little richer benefits) if their providers were in network and there was a good network in the area. (Now if a PFFS MAPD is $19 and the PPO is $65 you won't have many takers for the PPO, but with PFFS premiums going up the situation you describe will likely become more common.)
But it's really hard to say without taking a look at the plans and also knowing what degree of acceptance the PFFS has in the area. Most of my PFFS sales were to people in rural areas who had providers (and especially hospitals) who weren't in the PPO network. The vast majority were also to people who either couldn't qualify for or couldn't afford a Med Supp.
In general, I agree with what Frank has written about availability of quality health care.
If an HMO is available in the area and it was a plan that would meet the client's needs, I'd usually recommend that over either PPO or PFFS since the benefits were typically quite a bit better and it was very cut and dried with regard to who they could see. When selling a PPO, you need to be very careful to alert them to any deductibles that may apply to out of network services and that services rendered out of network will not count toward their in-network MOOP.
When the premiums and benefits were in the same ballpark, when I was regularly selling these plans, I usually recommended the PPO (which was typically a little cheaper and in some cases had a little richer benefits) if their providers were in network and there was a good network in the area. (Now if a PFFS MAPD is $19 and the PPO is $65 you won't have many takers for the PPO, but with PFFS premiums going up the situation you describe will likely become more common.)
But it's really hard to say without taking a look at the plans and also knowing what degree of acceptance the PFFS has in the area. Most of my PFFS sales were to people in rural areas who had providers (and especially hospitals) who weren't in the PPO network. The vast majority were also to people who either couldn't qualify for or couldn't afford a Med Supp.
In general, I agree with what Frank has written about availability of quality health care.
If an HMO is available in the area and it was a plan that would meet the client's needs, I'd usually recommend that over either PPO or PFFS since the benefits were typically quite a bit better and it was very cut and dried with regard to who they could see. When selling a PPO, you need to be very careful to alert them to any deductibles that may apply to out of network services and that services rendered out of network will not count toward their in-network MOOP.
Last edited:
Well...the OP said if everything else is equal...so I'm going with the PFFS. I've heard some dissension on here about the PFFS but never any reasons why.
Why would you not want the versatility of no network to deal with? I usually call the providers ahead of my appointment to make sure their Drs will file if I use a PFFS. Rural areas often have the biggest problem using an HMO or PPO.
Off topic, but this year all the choices have problems IMHO. Secure Horizons' AARP Plan 1 HMO looks pretty good except the Skilled N. Care is bass-ackwards, $80/day for 1 - 25. To me this is a problem. I like to see my clients be able to make some bigger claims and not spend more than they'd have spent had they had a supp.
PDPs this year are looking rediculous too.
Why would you not want the versatility of no network to deal with? I usually call the providers ahead of my appointment to make sure their Drs will file if I use a PFFS. Rural areas often have the biggest problem using an HMO or PPO.
Off topic, but this year all the choices have problems IMHO. Secure Horizons' AARP Plan 1 HMO looks pretty good except the Skilled N. Care is bass-ackwards, $80/day for 1 - 25. To me this is a problem. I like to see my clients be able to make some bigger claims and not spend more than they'd have spent had they had a supp.
PDPs this year are looking rediculous too.
- 7,066
The problem I have with PFFS plans, especially in rural areas, is that there is no network of doctors and hospitals.
Even though you "call the providers ahead", that does not mean that provider won't all of a sudden decide to get out of and no longer accept the PFFS plan that your new client has. There is no stability in the providers who accept any of the PFFS plans.
A woman called me last year and wanted a PFFS plan. After I explained it to her she opted for a Med Supp. She called me back several months later to tell me that her doctor, who did accept the PFFS plan when she initially contacted me, now has a sign up in his office saying that he no longer accepts any of the MA/PFFS plans.
Needless to say she was very thankful that I didn't let her take a PFFS plan.
That was last year, how many PFFS plans have already announced that they will not be offered for 2010? How many more will not be offered in 2011?
If I talk to a prospect in rural Missouri who insists on a PFFS plan I suggest that they contact another agent to take it with. I just don't sell them. I'm not comfortable recommending them to the prospects I talk to.
No, I'm not saying that other agents shouldn't offer them, I am just telling you why I personally don't. I'm sure I am walking away from a lot of money.
- 1,183
Other than perhaps home health, SNF is one of the biggest headaches with many plans. Some mirror what Medicare does and pays for the first 21 days, but other plans only pay for a handful of days. The plan you describe is the first one I've come across with a copay from day one.
When that benefit is used and the provider predictably says that "If you'd have had Medicare, it would have paid for the first 21 days" there is always going to be a certain percentage who will blame the agent, no matter how thoroughly the benefit was explained when sold, and no matter how much money they save on the other benefits. If a benefit is worse than what Original Medicare by itself pays, regardless of how the rest of the plan works, you're asking for trouble.
In my experience (admittedly based on anecdotal evidence) this benefit is (like home health) one of the most abused by providers looking to bilk Medicare.
- - - - - - - - - - - - - - - - - -
Frank, I'm also thinking that your conviction on this has earned you a lot of money as well, especially if the client realizes that you would rather lose the sale than sell PFFS. Too many agents are basically order takers who will happily sell something that the client is prepared to buy and either cannot or can't be bothered enough to provide professional service.
Again, I tend to agree with Frank here. If the situation warranted it, I could see selling an HMO or PPO because you can see the network in black and white, but I would be leery of PFFS at this point. With the cuts in provider reimbursement, I can foresee many more doctors refusing to accept them.
Calling one or two doctors to see if they accept the plans is fine, (and I've done that frequently in the past on behalf of clients or prospects) but consider that people aren't going to have the same doctor forever. Something may come up and they may need to go to a specialist who does not accept the plans.
Last edited:
- 7,066
Thanks.
I have always felt that credibility is the most important thing that I can offer a prospect or client. I have said it many times before, I don't sell insurance, I sell me.
It has served me well in the past and since it "ain't broken" I see no reason to start doing things differently now.
- 15,319
The pajama man always says to sell the plan with the highest commission.
Rick
Rick
Frank, your argument is going to be priceless if the present House reform bill passes. Under this proposal, Doctors are subject to a 21% cut in Medicare pay, and the MA program faces big cuts. I remember 2007: One particular rural county in Missouri that I prospected began hanging up those "No PFFS allowed" signs everywhere, and this was just a 10% cut. The AMA raised a stink and Congress repealed the cut. The AMA already tried to get this 21% cut lifted, but it failed to carry. Expect to see more "No PFFS" signs....
