An exclusive provider organization (EPO) is a type of health insurance coverage that allows you to obtain medical care from hospitals, doctors, and other care suppliers in your plan’s network except for an emergency. Typically, EPO plans only cover services provided by in-network suppliers. EPO plans might be less expensive than other health insurance programs if you stay in your plan’s network.
Many EPO programs require you to choose a primary care physician (PCP). A primary care physician is a doctor who can treat minor and chronic illnesses and provide preventive care treatments. However, a distinguishing feature of an exclusive provider organization is that you do not need a consultation from your primary care doctor to see a medical specialist. Other types of insurance coverages that necessitate you to have a family physician (such as an HMO) also require you to provide a recommendation from your PCP for medical specialist visits; otherwise, the insurance agency won’t cover the visit.
When you have an EPO plan, you will likely have to spend more out of pocket before your health plan begins to cover your medical bills. Nevertheless, EPOs may also provide lower monthly payments because the insurers in your network have agreements with your insurance company.
How does an Exclusive Provider Organization Plan Work?
Insurance carriers negotiate payment terms with physicians and facilities to establish a network of participating suppliers. When plan members receive services from those suppliers, according to the “agreed-upon rates,” the supplier bills the insurance company per service.
Mostly, you don’t need to choose a PCP (primary care physician) or obtain referrals to see specialists.
If you have an exclusive provider organization health plan, your insurer will not cover services provided by out-of-network suppliers unless you are in an emergency condition.
You might need to obtain pre-authorization, also known as prior authorization or prior approval, for your provider to cover certain services.
This is one method by which insurance companies keep their costs under control. Suppose your EPO plan does not authorize the coverage. In that case, your insurance company will not pay for the care. You might therefore consider going without treatment or paying out of pocket. Pre-authorization is required for various services, but the most common are imaging (MRIs or CT scans), hospitalizations, and expensive medications. Emergency care services do not require pre-authorization.
Generally, your medical specialist will request prior authorization from your insurance company. However, obtaining pre-authorization may be your responsibility. Double-check your insurance plan to be sure.
What are the Benefits of an EPO (Exclusive Provider Organization) Plan?
You have the option to select the provider you want to visit as long as they are available in your plan’s network. You won’t need to worry about deciding on a primary care physician or obtaining a referral from a primary care doctor before consulting a specialist. Also, you won’t even need to submit claims since your supplier will bill your insurance company directly at the agreed-upon rate.
Furthermore, EPO insurance plans are typically less expensive than other types of health insurance.
What are the Disadvantages of an Exclusive Provider Organization Plan?
EPO plans require beneficiaries to get medical care services only from in-network hospitals, doctors, and other providers. This means that you need to discontinue your visits if your preferred doctor does not accept your insurance. You must also ensure that your insurers are in-network before you travel.
What is the Difference between an EPO Plan and an HMO Plan?
Both EPO and HMO (health maintenance organization) plans require you to stay in your plan’s network and may not cover out-of-network services. Most HMOs, however, require members to select a primary care physician (PCP) and obtain referrals from the PCP to consult a specialist. Some EPO plans require primary care physicians, but they don’t need referrals.
What is the Difference between and EPO Plan and a PPO Plan?
Unlike EPO programs, PPO (preferred provider organization) plans cover services from both in- and out-of-network insurers. PPO plans typically have higher insurance rates and out-of-pocket costs than EPO plans in exchange for this flexibility.
What is the Difference between an EPO Plan and a POS Plan?
POS (Point of Services) plan combines the characteristics of both PPO and HMO plans. Unlike EPO coverages, POS plans may provide benefits from in and out-of-network insurers and require recommendations to consult specialists. POS offers multiple options, but they will have higher insurance premiums.
How does an EPO Plan Cost?
The cost of a health insurance policy varies depending on the carrier, geography, and plan. EPOs, on average, have lower premium costs and out-of-pocket expenses (such as coinsurance, copayments, or deductibles) than PPO plans. Check the cost details of any program you’re considering.
When Can You Use an Exclusive Provider Organization Plan outside of Network?
Health insurance policies, including EPOs, must include emergency care services at the same level as online care or at costs that are “reasonable and customary.” The emergency care facility might be allowed to deliver you a bill for any benefit that your health plan does not cover. However, many regions protect members from such expenses in case of true emergencies. If you have a mental or medical health emergency, your EPO will be required to cover it.
How common are the Exclusive Provider Organization Plans?
Among companies that offered at least one EPO or HMO plan in 2019, 13% provided EPOs, and 4% provided EPO and HMO plans. Businesses with 5,000 or more workers are more likely to give an EPO plan. Of those businesses, 22% provided EPO plans, while 11% provided both EPO and HMO policies.
Is an EPO Plan a Good Fit for You?
If you want to consult with medical service providers without worrying whether they are in your plan’s network, an EPO policy might not be the best choice. However, suppose you don’t mind limited insurance options in exchange for lower premium costs, and you do not want to obtain recommendations to see specialists. In that case, an EPO plan may be the best option for you.
Next Steps to Follow
If EPO health insurance coverage sounds like the perfect fit for you, search for the options available in your area. Check to see if any doctor or service you want to use is part of your provider network. Review the deductible, premium, and other costs to determine if the plan is within your budget. It is crucial to ensure that the insurance program meets your requirements before you sign up.