PPO vs HMO Coverage for Therapy & Counseling Services

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HMO vs PPO Definitions

What is an HMO?

Health Maintenance Organizations (HMOs) are a type of medical insurance that often only covers treatments provided by medical professionals employed by or under contract with the HMO.¹

Except in cases of emergency, out-of-network care is typically not covered. You might need to reside or work in an HMO’s service region to be eligible for coverage. HMOs frequently offer coordinated treatment with an emphasis on wellness and prevention.

What is a PPO?

A Preferred Provider Organization (PPO) is a form of health plan that enters into agreements with hospitals and other medical facilities to build a network of participating providers. If you use providers within the network coverage, your costs will be lower.

HMO vs PPO Insurance Benefits & Differences

The following are some of the benefits and differences between HMO and PPO insurance.

• Cost: HMOs are typically cheaper than PPOs.
• Choice: Except in emergency cases, out-of-network care is typically not covered by an HMO plan.²
• Flexibility: PPO plans allow you to obtain care from any healthcare provider, inside or outside the network, resulting in greater flexibility than HMOs.
• Primary Care Physician (PCP): HMO plans require you to select a primary care physician. Your chosen PCP coordinates all your healthcare treatments, while PPO plans do not necessarily require a PCP.
• Referrals: With an HMO, you must first make an appointment with your PCP, who will then recommend you to an in-network doctor who accepts HMO coverage for therapy. PPO coverage for therapy and other services does not require referrals.
• Filing Claims: You probably won’t ever need to submit a claim because HMOs only allow you to see in-network doctors and hospitals. This is so that the provider is paid directly by your insurance carrier. With a PPO, in some circumstances, you will need to pay a doctor directly for their services, resulting in a higher out-of-pocket cost, before filing a claim to be reimbursed. This is most frequently the case when you use out-of-network providers.

Do HMOs & PPOs Cover Mental Health Services, Therapy & Testing?

Yes, both HMO and PPO plans typically cover mental health services, therapy, and testing. However, the specifics of your PPO coverage for mental health testing or HMO coverage for mental health testing will depend on your particular plan.

Athena Care is in-network with most major health insurance plans. Filling out our free and confidential online insurance verification form is the best method to determine the specifics of your insurance coverage for therapy.

PPO benefits for mental health services and HMO benefits for mental health services will differ. A care coordinator will thoroughly review your PPO therapy coverage/HMO therapy coverage. They can then assist you with any questions or concerns you may have regarding PPO insurance for therapy and HMO insurance for therapy.

Athena Care’s multiple mental health treatment clinics in Tennessee are open Monday through Friday, 7:00 a.m. to 6:00 p.m. The scope of our mental health therapy services is broad but includes the following:

• Acceptance and Commitment Therapy (ACT)
• Cognitive Behavioral Therapy (CBT)
• Dialectical Behavior Therapy (DBT)
• Eye Movement Desensitization and Reprocessing (EMDR)
• Family Systems Therapy
• Parent-Child Interaction Therapy (PCIT)
• Behavioral Health Assessments, including ADHD and neuropsychological testing
• Virtual Visits

Insurance may be able to help cover the cost of therapy. Find out if your insurance can help with the costs by calling your insurance provider or by contacting us below. One of our care coordinators can help you navigate your insurance coverage and get the care you need.

Other Types of Insurance & Ways to Afford Therapy

The following are other types of insurance and ways to afford therapy:

• Medicaid: Millions of Americans, including qualifying low-income individuals, children, pregnant women, elderly adults, and persons with disabilities, have access to health coverage through state-managed Medicaid. The federal government and the states each provide funding to the program.³
• Medicare: A federal health insurance program for those 65 and older, some younger disabled individuals, and those with end-stage renal disease.⁴
• Payment plans: Some hospitals, clinics, mental health treatment providers, and related are willing to work out a payment plan schedule for clients who need flexibility in paying for services.
• Sliding scale: To lower costs for clients with limited resources, income-based clinics sometimes adopt sliding scale price structures. The amount due for services rendered to qualified patients is modified based on the patient’s capacity to pay.
• Exclusive Provider Organization (EPO): a managed care plan where treatments are only covered if you visit doctors, hospitals, or other healthcare providers in the network (except in an emergency).⁵
• Point of Service (POS): An insurance plan in which you pay less if you use hospitals, doctors, and other network healthcare providers. You also need a recommendation from your primary care doctor to see a specialist under POS plans.⁶
• High Deductible Health Plan (HDHP): An HDHP features a more expensive deductible than a standard insurance plan. Although monthly premiums are lower, the insurance company doesn’t begin to cover its share of your medical expenses until later. You can use money from an HDHP and a Health Savings Account (HSA) to pay for specific medical expenses that aren’t subject to federal taxes.⁷
• Local social services: Student health centers and federally recognized health centers, such as community-based clinics funded by the federal government, may offer free or inexpensive mental health care.
• University hospitals: Patients frequently have access to interns and residents on a sliding scale. Typically, this costs much less than hiring a mental health doctor in private practice.
• Non-profit options: Not-for-profit groups match inexpensive mental health treatments to middle and lower-income persons and their families.
• Employee Assistance Programs (EAP): Some employers foot the bill for these services, giving workers free use. The employee handbook or human resources division can provide more details on EAP benefits.
• Disability Benefits: You may qualify for disability benefits if your mental illness prohibits you from working and is severe or chronic. These benefits might not usually involve health insurance.