December 17,2019

Exclusive Provider Organization(EPO)

 

Have you considered enrolling in an EPO health plan? If so, then it’s important to understand exactly what these plans are and how they work, to make sure the plan will meet your needs.

 

What if you already have EPO health insurance? Understanding the ins and outs of how your EPO works will help you use your health plan effectively and avoid expensive mistakes.

 

An Exclusive Provider Organization (EPO) health insurance plan requires you to use the doctors and hospitals within its own network, much like their cousins, HMO and PPO, EPO health plans have cost-containment rules about how you get your health care. If you don’t follow your EPO’s rules when you get health care services, it won’t pay for the care. As an EPO member, you cannot go outside your plan’s network for care. Also note that there are no out-of-network benefits under an EPO health insurance plan.

 

How Doe’s it Work?

What do you need to know about using your EPO health insurance? Make sure to read your health insurance policy very carefully. Staying in-network and getting pre-authorizations when needed could save you a lot of money. Let’s look at the most important concepts to understand.

 

An exclusive provider organization, or EPO, is a health insurance plan that only allows you to get health care services from doctors, hospitals, and other care providers who are within a certain network. Your insurance will not cover any costs you get from going to someone outside of that network. The only exception is that emergency care is usually covered.

 

Many EPO insurance plans require you to select a primary care physician (PCP). A PCP is a doctor who can provide preventive care as well as treatment for minor and chronic illnesses. (You may also see people refer to a PCP as a general practitioner, family doctor, or pediatrician in the case of PCPs for children.)

 

Another defining feature of EPO plans is that you do not need to get a referral from your primary care physician in order to see a specialist physician. Other health insurance plans that require you to have a PCP also require you to get a referral from your PCP if you want the insurance company to pay for a visit to a specialist.

 

While an EPO restricts your health care options to the providers in your local network, this usually means you get lower monthly premiums because the providers in that network have contracts with your insurance company. On the flip side, an EPO health insurance plan often requires you to pay more out of pocket before your insurance starts covering your medical expenses.

 

The downside of this type of plan is that any provider outside of the EPO network isn’t covered by your insurance. But because of these limitations, EPO plans generally can be suited well to individuals who don’t anticipate needing a great deal of medical care and want to save money.

 

An upside to the EPO health insurance plan is that you usually don’t have to get referrals to see specialists, which makes the process a lot faster if you know what you need, and don’t want to go through a primary care provider to get it.

 

How to get an EPO plan

If you get group health insurance through your employer, you can only choose an EPO plan if your employer offers one.

 

If you don’t get insurance coverage through work, you can get an EPO through the marketplace. The Affordable Care Act created a marketplace where individuals can buy a health insurance policy. You will find EPO plans, so you can compare the costs and the specific plan benefits in order to choose the best option for you. In addition to your monthly premiums, make sure you consider the cost of co-pays (both in and out of network), coinsurance, deductibles, and the out-of-pocket maximum, which is the maximum you will ever pay before insurance starts covering 100% of your costs.

 

Whether you get a plan through work or the marketplace, you can only choose a new plan during Open Enrollment, a period from November to December when anyone can get an insurance policy. If you change jobs or experience a major life change, like the birth of a child, you may qualify for Special Enrollment, which allows you to enroll in a new plan outside of the Open Enrollment period.

 

You Don’t Have to File Claims

You don’t have to hassle with bills and claim forms when you have EPO health insurance since all of your care is provided in-network. You’re in-network health care provider bills your EPO health plan directly for the care you receive. You’ll just be responsible for paying your deductible, copayment, and coinsurance.

 

Bottom Line on EPO Health Insurance

Confused yet, great, don’t feel bad, you’re in the same boat as for the other million or so consumers trying to put it together. Let me some this up. EPO’s have some traits in common with HMOs and some traits in common with PPOs. As such, you might consider an EPO to be a cross-breed between an HMO and a PPO: Like an HMO, you have to stay within the plan’s network. But like a PPO, you’re not required to get a referral from your premium care doctor in order to see a specialist.

 

Many people like the ease of being able to schedule an appointment with a specialist without consulting a primary care physician. At the same time, this can sometimes be a challenge in that you are limited to certain specialists within your network. Having an EPO also requires you to actively get involved in planning expensive services or procedures, and leaves you primarily responsible for completing any prior authorizations required. Overall, the combination of its low premiums and low cost-sharing make EPOs a good choice for many people. If you are finding it mind-boggling as you compare different plans.