In-network versus out-of-network services
There are quite a few terms you need to know to understand your insurance coverage, particularly when it comes to benefits surrounding pediatric therapy. One such concept is in-network versus out-of-network providers. What is the difference, and how can this affect services for your child who might have developmental, emotional, or physical challenges?
Here is our brief overview of in-network and out-of-network benefits.
How insurance works
There are several different types of insurance, from plans that are part of the insurance marketplace to individual and employer-provided plans. Each has different benefits and levels of coverage, as well as varying amounts when it comes to premiums, deductibles, copayments, and coinsurance.
Most commercially available plans fall under one of four categories:
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
- EPO (Exclusive Provider Organization)
- POS (Point of Service)
Almost all these plans have rules regarding in-network and out-of-network services to varying degrees.
In-network versus out-of-network services
In-network services refer to health care providers who have contracted with your insurance company to provide services at negotiated or discounted rates. The provider could be a pediatrician, specialist, hospital, medical clinic, diagnostic center, urgent care center, or therapist.
Here’s an example of how in-network benefits work. Let’s say you take your child to a specialist. The total charge for the visit might be $250. However, since the doctor is part of your plan’s network (in-network), he or she agrees to provide a discount of $75. Your insurance then pays $140, while you pay the remaining $35 as your copayment.
An out-of-network provider is not contracted with the insurance company, so there is no agreed-upon discount.
Most insurance plans prefer for you to go to an in-network provider for obvious reasons. In fact, some require you to use only plan providers, or they will not pay for the services. Others allow you to see out-of-network providers but at a higher cost.
Here’s a basic breakdown:
- HMO – Required to see in-network providers only.
- PPO – Can see out-of-network providers, but for a higher cost.
- EPO – You have more freedom to choose a provider. However, these plans do not usually cover the cost of out-of-network services.
- POS – These plans are a blend of HMO and PPO, allowing you to see out-of-network providers for a higher cost.
It’s important to understand this distinction and be clear about whether a provider is part of your network. Otherwise, you could end up paying a lot more for health care services and therapy.
If you are in doubt, call the specific provider and ask what insurance they accept or call your insurance company directly.
Assistance with pediatric therapy services
Even with good insurance, many families still struggle to afford the cost of on-going therapy. Lumiere Children’s Therapy offers membership plans with discounted rates for sessions. We can also identify resources that can help you pay for things that may not be covered.
Lumiere Children’s Therapy Services
Lumiere Children’s Therapy provides comprehensive treatment and support for children. We also work to educate families and caregivers. Above all, our mission is to inspire hope that your child can improve and achieve traditional milestones. We strive to create experiences that help forge connections between parents and children, while also revealing the potential in each child, regardless of their skills.
- Speech therapy
- Occupational therapy
- Developmental therapy
- Physical therapy
- ABA therapy (Applied Behavior Analysis for Autism Spectrum Disorder or ASD)
- Social work
- Augmentative alternative communication
- Early intervention
If your child is struggling with speech, physical impairments or developmental delays, we can help. And we will do our best to work with your insurance and other sources of funding to provide the services your child needs.
Lumiere Children’s Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians works to improve the lives of children and their families.