Making Sense of Your Health Insurance Benefits

What’s Your Plan Type?

Written By: Caitlin Burke

Radiant Moments Pediatric Therapy initially operated as a private pay only practice.  Admittedly, this was because I lacked a basic understanding of how insurance actually worked. 

I knew that in order to have an impact on more children and their families, I would need to dive head first into the insurance world.  So, I did what I do with everything…  I went down the insurance rabbit hole and learned everything I could.  

It feels great to be able to help families understand their health insurance benefits so that they can make informed decisions and reduce out-of-pocket costs.  Let’s break down health insurance benefits together!

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Which Plan Type Do You Have?

• Health Maintenance Organization (HMO):  An HMO plan offers a local, limited network of providers.  HMO plans typically do not have out-of-network benefits so if you choose to see someone who is out-of-network, you will pay 100% of the cost.  In order to see a specialist (speech therapist), you will likely need a referral from your child’s pediatrician. HMO plans usually have lower monthly premiums and out-of-pocket costs than PPO or EPO plans.

• Preferred Provider Organization (PPO):  A PPO plan is the most flexible plan as it offers a larger network of providers and you often do not need a referral from your child’s pediatrician to see a specialist (speech therapist).  These plans also tend to have out-of-network benefits.  Monthly premiums and out-of-pocket costs are usually the highest with this plan.

• Place of Service (POS):  A POS plan combines aspects of both HMO and PPO plans. While you can see providers who are out-of-network (with your out-of-network benefits), you often need a referral from your child’s pediatrician to see a specialist (speech therapist).  This plan is more flexible than an HMO plan, but less expensive than a PPO plan.

• Exclusive Provider Organization (EPO):  An EPO plan also combines elements of HMO and PPO plans.  It is less expensive than a PPO plan (with lower monthly premiums).  You do not need a referral from your child’s pediatrician to see a specialist (speech therapist).  However, if you choose to get care outside of your plan’s network, it may not be covered (except in an emergency) as there are no out-of-network benefits.

At Radiant Moments, we try our best to help you understand your benefits from the start for full financial transparency!