What's Your Health Plan Type?

Making Sense of Your Health Insurance Benefits, Part 1

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.

Do You Have a High- or Low-Deductible Health Plan?

• High-Deductible Health Plan:  With a high deductible plan, you can expect to pay more upfront before insurance starts covering medical costs.  As of 2025, a high deductible plan is one with a deductible of at least $1,650 for an individual or $3,300 for a family.  With these plans, you pay less in monthly premiums and are eligible for a Health Savings Account (HSA).  For speech therapy services, you would expect to pay the full contracted amount until you met your deductible.  After meeting your deductible, you would likely pay your coinsurance (% of full contracted amount) until meeting your out-of-pocket maximum.  Upon meeting your out-of-pocket maximum, insurance would pay for speech therapy in full.  Please know that it is possible that your high deductible plan has copays as opposed to coinsurance, but this is less common.

• Low-Deductible Health Plan:  With a low deductible plan, insurance starts covering medical costs sooner and you can expect higher monthly premiums.  These plans are usually not eligible for a Health Savings Account (HSA).  For speech therapy services, there is likely to be a flat copay that is due at the time of each visit.  Usually, copays start immediately without needing to meet your deductible.  There are low deductible plans for which there is a coinsurance that kicks in after meeting the deductible. 

In summary, each health insurance plan is unique and it is best that you know how your plan impacts your out-of-pocket costs for speech therapy.

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