An Exclusive Provider Organization (EPO) is what, exactly?

An Exclusive Provider Organization (EPO) is what, exactly?

An exclusive provider organization (EPO) plan is a type of health insurance that forces users to use a set network of doctors, hospitals, and other healthcare providers unless it’s an emergency. Most EPO plans only cover services from companies that are part of the plan’s network. If you stay in-network, EPO plans may cost less than other types of health plans.

Key Takeaway

Exclusive provider organization (EPO) plans only let users see doctors and other specialists in a certain network.

Most of the time, preferred provider organization (PPO) plans cost more than EPO plans.

Most EPOs don’t cover care from providers outside of their network. This means you’d have to pay out of pocket for care from providers outside of your network.

How does a plan for an EPO (Exclusive Provider Organization) work?

Health insurers work out payment plans with doctors and hospitals to make a network of providers who will take their plans. When people with a health plan get services from these providers, the providers send the insurance a bill for each service based on the fees they agreed to.

Most of the time, you don’t have to choose a primary care doctor (PCP) or get a recommendation to see an expert.

If you have an EPO plan, your insurance company won’t pay for services from sources outside of their network unless it’s an emergency.

What are the benefits of an EPO plan?

As long as the source is in the network, you can choose who to see. Before you see an expert, you probably won’t have to choose a PCP or get a recommendation from a PCP. You won’t have to make claims either, since your service will send the agreed-upon rate straight to your insurance.

Also, EPO insurance plans are often cheaper than other types of health insurance.EPO plans don’t need recommendations, so you can see any expert in the network without filling out any paperwork.

What are the cons of a plan with an Exclusive Provider Organization?

Members of EPO plans can only get health care services from doctors, hospitals, and other sources who are part of the plan’s network. If your favorite doctor doesn’t accept your plan, this could mean you have to stop seeing them. You are also responsible for making sure that your sources are in-network before you leave.

What’s the difference between an EPO plan and an HMO plan?

Both EPO and HMO plans require you to stay in-network and may not pay for the care you get outside of the network. Most HMOs, on the other hand, require users to pick a primary care physician (PCP) and get a recommendation from the PCP to see an expert. There are EPO plans that require a PCP but don’t require recommendations.

What’s the difference between an EPO plan and a PPO plan?

PPO plans, which are different from EPO plans, cover services from both in-network and out-of-network providers. In return for this freedom, PPOs tend to have higher rates and out-of-pocket costs than EPO plans. Members of both kinds of plans can see experts without a recommendation.

What’s the difference between an EPO plan and a POS plan?

Point-of-Service (POS) plans to blend parts of both HMO and PPO plans. POS plans are different from EPO plans in that they may cover services from both in-network and out-of-network sources and may require a recommendation to see an expert. POS plans to give you more freedom, but the fees may be higher.

When can you go outside of your plan’s network if you have an EPO?

Health insurance plans, including EPOs, must cover emergency care at the same level they pay for in-network care or at rates they find “reasonable and customary.” The hospital or emergency room may be able to send you a bill for what your health insurance doesn’t cover, but many states protect people from such bills in true situations. If you have a mental or physical health problem, your EPO must pay for it.

Always Prepared for Emergencies
No matter if the care is in the network or not, emergency care is covered.

How common plan with exclusive providers?

In 2019, 13% of companies with at least one HMO or EPO plan also had EPO plans, and 4% had both HMO and EPO plans. EPO plans are more likely to be offered by companies with 5,000 or more workers or more. 22% of these businesses had EPO plans, and 11% had both HMO plans and EPO plans.

Should you get an EPO plan?

An EPO policy may not be the best choice if you want to see doctors without thinking about whether or not they are in your insurance network. But an EPO plan could work for you if you don’t mind a smaller network of providers in return for lower health insurance costs and don’t want to get recommendations to see experts.

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