Choosing Health Insurance: What You Need to Know


It’s just a fact of parenting: try as we might, we can’t 100% control what our kids do. Whether it’s a fall on the monkey bars or a nasty germ picked up at school, it’s only a matter of time before your child is going to need some sort of medical attention.

Health insurance is important to making sure your child can receive whatever medical attention they might need, but when choosing an insurance plan, the options can be overwhelming. Don’t worry, though – we’re here to break it down for you.

First, you’ll need to choose what type of insurance plan you want: a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or High Deductible Health Plan (HDHP).


Health Maintenance Organizations

Health Maintenance Organizations often provide integrated care and focus on prevention and wellness. HMOs offer a range of health benefits for a set monthly fee. You must use the providers and facilities within their network to receive coverage, except for emergencies. Most HMOs require a small copay for each visit, and generally provide well care services at lower out-of-pocket cost.


Preferred Provider Organizations

In a Preferred Provider Organization, doctors, hospitals, and other providers agree to accept lower fees from the insurer in exchange for being part of the network. Because of this, your costs should be lower than if you go outside of the network. If you choose to get care outside of the network, you will have to meet your deductible and pay a percentage of the total cost.


High Deductible Plans

High Deductible Plans include large deductibles that the family is responsible for, and insurance kicks in after the deductible is met. If you have a HDP, you are able to set up a Health Savings Account, a type of savings account that allows you to set aside money before taxes to cover certain medical expenses. Note that all high deductible plans purchased after March 10, 2010 must include 100% coverage for preventive services even if the deductible has not been met.


Not too complicated, right? Once you’ve decided what type of plan may be right for you, here are a few things you should consider before choosing a specific plan:


Total cost

Make sure you understand the fee structure of the plan options and what you’ll ultimately be paying. In general, if you pay less for premiums, you will pay more in copayments, deductibles, etc.


Coverage & Benefits

Make sure you know the answers to the following:

●      How does the plan cover your family members with special health care needs?

●      Are there any benefit carve outs? Benefit carve outs are when a defined category of services or diagnoses are not included in the coverage.

●      If there are benefit carve outs, what will it cost you to fill the gap?

While your child might be relatively healthy and doesn’t have any special medical needs, that doesn’t mean you should go light on coverage. We can’t always be there to keep our kids from taking risks, and a broken arm from tree climbing can put your child in the ER with an expensive price tag. Make sure your plan either covers sick visits/ER trips or that you will able to cover them should the need arise.



Very few people think to look into the appeals process of a plan before they commit, but it can be a huge cost-saver. Most denials are unchallenged because members don’t know about their right to appeal or have no idea how the process works, and appealing a denial can help you secure cost savings for critical services.


Before you choose a new plan, be sure to confirm that PIP (and any of your favorite personal health providers) are able to accept that plan. If PIP is not in that “network” your family may have to pay higher copays or even switch clinics. We are always sad to see a family leave – so if you have any question about coverage, contact us through the Patient Portal or by phone. We’ll be more than happy to help answer these questions!

Choosing insurance can be a daunting process, but it doesn’t have to be. When you understand the types of plans and know what to look out for, you can make an informed decision that is right for you and your child.

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