PPO isn't automatically better. HMO isn't automatically better. The right network depends on the client sitting in front of you.
When PPO May Matter
- Greater provider flexibility on some plans
- Ability to use certain out-of-network providers when the plan permits it
- Less dependence on a tightly restricted local network
- Referral requirements may differ by plan — some PPOs don't require them
"How important is flexibility to see any provider?"
"Do you travel or spend time outside your local area?"
"Is there a specific specialist you want to keep seeing regardless of network?"
"Have referral requirements ever caused delays for you?"
When HMO May Matter
- Lower applicable copays on some plans
- Strong local network with coordinated care
- A PCP who helps coordinate specialist care
- Existing doctors may already participate in the network
- Potentially richer supplemental benefits, depending on the plan
"Are all of your doctors already in this network?"
"Is lowering your medical costs more important to you than out-of-network flexibility?"
"How often do you actually see doctors outside your network today?"
Don't overgeneralize
Not all HMOs require referrals, and not all PPOs allow unrestricted out-of-network access. Verify the specific rules of the plan you're discussing rather than relying on what HMO or PPO "usually" means.
PEAK rule
Never sell HMO vs. PPO based on the letters alone. Sell the reason the network structure fits this beneficiary.