Understanding Health Insurance Plans: Fundamentals to Help you Navigate Your Mental Health Benefits

Source: Photo by Edu Lauton on Unsplash

Understanding the details of health insurance policies is hard! As Wildflower’s Practice Manager, I see firsthand just how challenging (and frustrating) navigating health plan benefits can be. I empathize and understand these reactions––insurance plans are increasingly complex, nuanced and filled with fine print.

It is important to develop a solid understanding of your health insurance policy. This can help prevent the distress of unpleasant surprises related to costs of medical and mental health services and help you advocate for yourself when your plan is not paying for services in the way it should. When it comes to health insurance, the old adage that knowledge is power could not be more true.

In this educational article, I will provide general information about health insurance plans. To receive detailed information about your specific plan, it is always recommended to call the customer service number on the back of your insurance card.

In an effort to minimize the complexity of the information provided, I am going to focus on three areas: PPO vs. HMO, common benefit terms, and what information to ask for when requesting a benefits check from your insurer.

Let’s start with the differences between a PPO and HMO plan. There is no absolute “right” or “wrong” when it comes to picking a plan type; you need to pick a plan that is most suitable for your needs as far as premium costs, the benefit details, and access to in-network providers. Benefits change from plan to plan and also from year to year. Even if during your enrollment period you select the same plan you had before, it is important to re-verify specific benefits and costs every year.

PPO stands for Participating Provider Organization. This type of health plan allows you to choose where you would like to go for care without a referral from a primary care provider (PCP) or without having to choose from a limited list of approved providers. PPO plans typically have a higher premium per month but do not require a referral from a PCP to coordinate care or see a specialist and provide access to a broader, more extensive list of providers. Under the umbrella of PPO plans, it is common to have various “tiered” PPO options. These tiered PPO plans likely have different premiums per month and coverage details, but all function generally as a PPO plan.

HMO stands for Health Maintenance Organization. This type of health plan generally keeps costs lower and predictable. It involves choosing one primary care doctor (PCP) who coordinates your care. HMO plan types typically have a lower premium per month but you are only able to access providers in your specific HMO provider network. A limitation to this plan type is that you must first see your PCP provider in order to obtain a referral to see a specialist (including for mental health).

After deciding the most appropriate plan type for your needs, you will want to get familiar with common benefit terminology. This will help you understand your benefits and what they actually mean in terms of coverage and out-of-pocket costs.

Deductible: A deductible is the amount you pay out-of-pocket before your health plan starts to pay for services rendered. For example, if your deductible is $1,000, you will pay $1,000 out-of-pocket, before your health plan begins to pay a portion or all of the costs for a particular service.

Co-Insurance: In most instances, after your deductible has been met, a co-insurance is applied. Co-insurance is when your plan covers a large portion of the cost of care, and you are responsible for the remaining portion. For example, if your plan has 80/20 co-insurance for in-network services, your health plan will pay 80% of the cost, and you are responsible for the remaining 20%. The percentage breakdown varies depending on your specific plan.

Copay: A copay is a fixed amount that you are responsible for paying each time a service is rendered. The copay amount can differ based on what type of provider you are seeing. For example, a primary care provider visit may be subject to a copay of $30 and seeing a specialist may incur a cost $50. The copay amounts vary depending on your plan, and oftentimes the amounts are listed directly on your insurance card. If they are not listed, the quickest way to find that information is to call the number on the back of your insurance card or sign into your online portal (if applicable). It is important to note that in most cases copays do not count towards meeting your deductible, but do count toward your out-of-pocket maximum.

Out of Pocket Maximum (OOPM): This is the most you will have to pay out of your own pocket per year before your health care plan covers services at 100%. The out-of-pocket maximum differs for every plan. For example, if you reach your OOPM for the year, a visit that you may have previously paid $30 for will be covered at 100% by your health care plan with no expense for you. OOPM resets every year. Note that out-of-network services will not count towards your in-network out-of-pocket maximum. You may have a separate out-of-pocket maximum for out-of-network services. All of this information can be confirmed by contacting customer service for your individual plan.

How and why should I do a benefits check?
I cannot emphasize enough the importance of calling your insurance plan for a benefit estimate before you go in for any appointment. While insurance plans do not guarantee coverage until claims are processed, calling ahead of time will provide you with the expected cost of a service and give clarification about any limitations within your specific plan that may impact your coverage.

The information that is most useful to gather before calling your insurance plan can be obtained from your provider. You will want to ask who the rendering provider will be (this could be an MD, a licensed social worker, a nurse practitioner, etc.), and what the CPT (Current Procedural Terminology) codes are for the services that are going to be provided. Once you collect this information, you will be able to directly ask your insurance representative for your benefit estimates for the specific CPT codes rendered by the provider.

Outpatient Mental Health Services: When it comes to in-network outpatient psychotherapy, most common insurance plans process psychotherapy claims in one of two ways. The first way is that the member is responsible for a copay for each session. As mentioned above, the amount of the copay will vary from plan to plan, but the member should expect to pay the same amount each visit until their OOPM has been met for the year. The second way is that psychotherapy visits will process towards the member’s deductible, and once that is met, a co-insurance will kick in, making the member responsible for a percentage (varies by plan) of the total cost of the service. This means that the member will initially pay a higher amount out-of-pocket until their deductible is met. Each visit amount can vary based on the type of appointment.

Insurance Information Specific to Wildflower
At Wildflower, all of our clinicians are considered in-network with Blue Cross Blue Shield (BCBS) PPO plans, Blue Choice PPO plans, and select clinicians are in-network with UnitedHealthcare/Optum PPO plans. Wildflower clinicians are out-of-network with all other insurance companies (this includes BCBS & UHC plans that use third party payers for mental/behavioral health benefits and BCBS HMO plans) which means that we do not bill them directly. If you are interested in learning more about your behavioral/mental health care coverage, our FAQ page provides a more exhaustive list of specific questions for you to ask your insurance representative.


Insurance Basics (2015-2021). https://connect.bcbsil.com/tags/Insurance%2bbasics