invited you to try Thrizer! Start your free trial and enjoy waived credit card fees for your first in charges.
Three types of health insurance plans typically offer insured individuals out-of-network benefits:
Others, like health maintenance organizations (HMOs) and exclusive provider organizations (EPOs), only offer out-of-network benefits in emergency cases.
Also, funds from health savings accounts (HSAs), flexible savings accounts (FSAs), and health reimbursement arrangements (HRAs) may be used to pay for therapy not covered by insurance.
When you run a private pay therapy practice, it’s important to understand which types of plans offer out-of-network benefits and which do not. That information helps you plan your:
Here’s a detailed breakdown of which types of insurance plans provide insured individuals out-of-network benefits, including how common each type is, their typical premiums and deductibles, and what you can do to attract clients with coverage.
This article draws heavily on the Kaiser Family Foundation (KFF) 2025 Health Benefits Survey. The annual survey is an industry standard for tracking employer-sponsored health insurance.
PPO and POS plans both offer out-of-network benefits, and so do high deductible health plans with savings options (HDHP/SOs) with PPO or POS structures. Insured individuals with these types of coverage are good potential clients for your private pay practice.
PPOs are the most common employer-sponsored plans. Insured individuals can see any in-network provider and pay in-network deductibles with in-network out-of-pocket maximums. They can also see providers outside of the insurance network, but out-of-network care has higher deductibles than from in-network care and out-of-pocket maximums are not capped by federal mandates.
Insured individuals typically don’t need a referral to see a provider either in-network or out-of-network.
In 2025, 29% of companies offering health insurance to employees offered PPO plans. And, in total, 46% of covered workers overall had PPOs.
In 2025, the average PPO premium was $9,818 for single coverage and $28,272 for family coverage.
In-network, the average deductible for single coverage was $1,252, with federally mandated out-of-pocket maximums set at $9,200 for self-only coverage and $18,400 for family coverage.
With PPO plans, out-of-network deductibles are typically two to three times the amount of in-network deductibles. You can expect that a typical PPO insured individual would have a deductible of $2,500 to $3,750. Federally mandated out-of-pocket limits do not apply to out-of-network care, so they’re typically higher than they are in-network.
Large employers are far more likely than small companies to offer employees PPOs. As a result, white-collar workers, government staff, university employees, and employees of major corporations are disproportionately more likely to have PPO coverage.
Because of their relatively high premiums, PPOs are more affordable for people in higher income brackets. Also, individuals with ongoing health conditions and complex medical needs may prefer PPOs to other plans, because they don’t need to wait for referrals from primary care providers to see specialists.
A point of service (POS) plan is similar to a PPO. Insured individuals are covered both for care within the insurer’s provider network and for out-of-network care. The big difference: With a PPO, an in-network primary care provider (PCP) acts as a gateway to specialist care. Insured individuals need a referral from their PCP for specialist treatment, hospital visits, and—often, but not always—out-of-network care.
In 2025, only 9% of covered workers had POS plans. That’s a small number overall, but it makes up a significant portion of individuals with out-of-network benefits. Also, the POS niche is stable. While other plan types have risen and fallen in popularity over the years, POS enrollment has stayed at a 9% – 11% share.
Unlike with other plan types, the KFF survey does not publish average deductibles for POS plans. And premiums vary widely depending on age and plan tier. Typically, though, the premium for a POS plan is lower than a PPO but higher than a health maintenance organization (HMO) plan.
As an example, the average monthly premium for a Silver-tier POS plan for a 40-year-old individual is $661 ($7,932 per year).
Some POS plans charge no deductible for in-network care, and none for out-of-network care provided the insured individual has a referral from their PCP. But the majority of POS insured individuals do pay a deductible, and in 2025 it averaged $1,886 for individual, in-network care.
As with PPO plans, POS plans have a higher deductible for out-of-network care. And federally-mandated caps on out-of-pocket costs do not apply to out-of-network care.
POS plans are most commonly offered by smaller companies in the Northeast. States like New York, Massachusetts, New Jersey, and Connecticut have denser POS provider networks than other parts of the country, making them more popular there.
Workers who choose POS plans are more likely to be budget-conscious but still looking for flexibility of care. They may not believe they can justify the higher premiums of a PPO plan, but still want to be able to access out-of-network care with benefits when necessary.
HDHP/SOs are a distinct form of health coverage that has rapidly grown in popularity since the early 2000s. At its core, an HDHP/SO charges low premiums but relatively high deductibles, with an optional savings plan attached that can help insured individuals cover deductible costs.
The plan itself may be structured like a PPO, POS, HMO, or EPO, the only difference being its low premium and high deductible. The savings option may take the form of a health savings account (HSA) or a health reimbursement arrangement (HRA) sponsored by an employer.
Individuals with HDHP/SO plans have out-of-network benefits when their plan is structured as a PPO or POS.
After PPOs, HDHP/SOs are the most popular form of insurance among covered workers. In 2006, when KFF began tracking enrollment, the portion of covered workers with HDHP/SO plans was effectively zero. In 2025, it was 33%. From 2008 to 2018 alone, enrollment increased from 8% to 29%.
In 2025, the average premiums for HDHP/SOs were $8,620 for single coverage and $25,379 for family coverage. That’s well below the $9,818 and $28,272 averages (respectively) for PPOs.
Deductibles for individual HDHP/SO plans range from $2,500 – $3,000 or more on average. That’s significantly higher than the $1,252 average for PPOs. Employees at smaller companies tend to have higher deductibles and receive lower employer contributions to HSAs or HRAs.
It’s savings options that make HDHP/SO attractive to so many employees. In 2024, 68% of employers offering single coverage and 77% offering family coverage with an HSA-qualified plan contributed to their employees’ accounts. And in 2025, 33% of covered workers with an HDHP/SO that included an HRA received employer contributions for single coverage that was greater or equal to their deductible amount. An additional 19% of employees with HRAs—and 10% with HSAs—received contributions that would lower their individual annual liability to $1,000 or less.
Out-of-pocket maximums are the same as they are with PPO and POS coverage. For plans with out-of-network benefits, the federally-mandated caps apply only to in-network care.
Employees who choose HDHP/SO plans are more likely to be young and healthy, with few chronic health conditions requiring frequent care. They also often work for large companies; HDHP/SO prevalence increases in tandem with the size of employers offering plans, and larger employers typically make more substantial contributions to employees’ HSAs or HRAs.
Many larger employers have also moved towards exclusively offering HDHP/SOs, making them less of an option for employees than a necessity.
But HDHP/SOs are also popular with self-employed individuals, particularly for those who don’t qualify for significant subsidies and want to minimize monthly premium costs. The 2025 budget changes made HDHPs with HSAs available to marketplace enrollees and improved access to telehealth.
Finally, income level plays a role. Workers in higher income brackets may be more comfortable shouldering the risk that comes with high deductibles.
Individuals with coverage through PPO, POS, and HDHP/SO plans all enjoy out-of-network benefits. They’re good candidates for clients of your private pay therapy practice.
On the other hand, those with HMO and EPO coverage do not have out-of-network benefits, and they may not be a good fit unless they’re willing to pay 100% out of pocket.
Keep in mind that an HDHP/SO structured as an HMO or EPO also lacks out-of-network benefits.
HMO plans provide no out-of-network coverage except in case of emergencies.
EPO plans also lack out-of-network coverage, but they differ slightly from HMOs. An individual insured by an EPO plan does not need a PCP referral to see a specialist. But any specialist they see must be in-network.
The KFF survey combines HMOs and EPOs into a single category, defined by a lack of out-of-network benefits. In 2025, 12% of covered workers were enrolled in HMOs/EPOs.
Plans without out-of-network benefits have seen a recent decline. In the late ‘90s, approximately 30% of covered workers had HMO or EPO plans. That decreased to 14% by 2015. Since 2022, total enrollment has fluctuated between 12% and 13%.
An HSA doesn’t provide out-of-network benefits. It’s a tax-free savings account for qualified health expenses. It may be provided in addition to a plan structured as a PPO or POS, which does offer out-of-network benefits.
However, funds in an HSA can be used to pay for care not covered by insurance, including out-of-network therapy.
The funds in an HSA roll over each year. If they’re not spent, the total amount increases over time with contributions.
Like an HSA, an FSA is a savings account, not a form of insurance coverage.
Also like an HSA, the funds in an FSA can be used for qualifying healthcare costs not covered by insurance. That includes out-of-network therapy.
Unlike an HSA, the funds in an FSA do not roll over.
Like an HSA or an FSA, an HRA is not a form of health insurance. It’s an arrangement that reimburses employees tax-free for healthcare costs.
However, most HRAs reimburse employees for funds spent on care not covered by insurance, including out-of-network therapy.
Individuals with out-of-network benefits may be more willing to see a therapist outside their insurance network than those without. That makes them good potential clients for your private pay practice.
To attract clients with out-of-network benefits, adjust your marketing and messaging, educate new clients, provide added benefits support, and ensure a transparent intake process.
You can tool your marketing efforts specifically to appeal to clients with out-of-network benefits by highlighting the fact that you provide superbills on request, or offer extra support through solutions like Thrizer.
Depending on your marketing channels, you may also be able to target keywords related to out-of-network therapy (through Google Ads) or target demographics more likely to have out-of-network coverage (through social media ads).
In terms of referrals, consider contacting major employers in your area that sponsor PPO, POS, or HDHP/SO plans for their employees. There may be opportunities to provide workshops or “lunch and learn” talks, helping you attract potential clients with coverage.
Educating your clients on out-of-network benefits can help ensure they keep coming to you for care. Many therapy clients are unaware they even have out-of-network coverage for therapy.
Helping them determine their coverage amounts and deductibles and guiding them through the superbill claims submissions process lowers the barrier to entry. That makes therapy more affordable for clients without affecting your bottom line—something which benefits you in the long run.
When clients use out-of-network benefits for therapy, they pay 100% of your fee upfront. Then they submit a superbill to their insurer to be reimbursed for the coverage amount.
That creates extra paperwork for them. It also puts a dent in their cash flow as they wait to be reimbursed.
With Thrizer, your clients only have to pay their out-of-pocket cost (after hitting their OON deductible) for therapy, and you receive your full fee upfront. There’s no need for you to prepare a superbill, and no need for your client to submit one. Thrizer does the work of obtaining reimbursement from the insurance company.
A solution like Thrizer makes therapy more affordable and manageable for clients. Not only does it help with client retention, but advertising the fact in your marketing materials can help attract clients who otherwise wouldn’t consider seeing a therapist out-of-network.
As part of your intake flow for new clients, make it clear how much you charge per session and how you support clients with out-of-network benefits. Note that you provide superbills upon request or simplify the process with Thrizer.
Also, explicitly note that reimbursement times and coverage rates depend on individual insurers. And if you offer sliding scale fees, mention the fact.
A transparent intake process helps ensure clients have all the information they need so they can plan their finances. They won’t be surprised by long reimbursement periods or low coverage rates, or blame you for them. The result is a stronger client-therapist relationship, potentially with better treatment outcomes and longer client retention.
—
Considering the switch to private pay therapy practice? Check out How Does Out-of-Network Insurance Work for Therapy?
This blog post is provided for informational purposes only and is not intended as legal, business, medical, or insurance advice. Laws relating to health insurance and coverage are complex, and their application can vary widely depending on individual circumstances and state laws. Similarly, decisions regarding mental health care should be made with the guidance of qualified health care providers. We strongly recommend consulting with a qualified attorney or legal advisor, insurance representative, and/or medical professional to discuss your specific situation and how the laws apply to you or your situation.we
