What is an EPO Plan?

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Basic Understanding of An EPO

An Exclusive Provider Organization (EPO) plan is a health insurance plan that only provides coverage for medical care within a specific provider network. Coverage is not provided for out-of-network service costs, unless they are related to a medical emergency. Under the Affordable Care Act (ACA), insurers are required to preserve their in-network emergency policies for out-of-network emergency visits, so costs incurred from ambulatory services or impatient care will be partially covered by an EPO plan. If you are using an out-of-network service provider in a non-emergency, however, EPO plans will not provide coverage.

Costs of an EPO Plan

Depending on your specific EPO plan, cost-sharing structures can vary. Some EPOs may have high cost-sharing and other low cost-sharing. But in general, EPO plans are one of the most economical insurance choices. Premiums are typically low because members have a limited scope of service providers. You will only be responsible for paying copayments, coinsurance, and deductibles, which are also lower than non-EPO plans on average. You will have to pay out-of-pocket for any medical expenses you incur from out-of-network providers.

How Referrals Work in This Network

EPO plans do not require you to have a referral to see a specialist. As long as the specialist or service provider is within the network, your EPO plan will provide coverage for the visit and allow you to see them without approval from a primary care physician. Although this can offer more control, you may have to get pre-authorization for certain high-cost services – such as surgeries, MRIs, or at-home medical equipment. Pre-authorization is required before your insurance company will pay for specialist services. This is a cost-saving technique that ensures you are not receiving any unnecessary expensive medical treatments.

Is a Primary Care Provider Required in an EPO?

A Primary Care Provider (PCP) is a doctor or general practitioner who provides preventive care and treatment for minor illnesses. With EPO plans, you don’t need to see a PCP before getting a referral to a specialist, so many EPO plans won’t require you to choose one. However, some insurers may require policyholders to choose a PCP within the network. 

How Does It Compare To Other Insurance Plans

There are various types of insurance plans that offer different benefits to policyholders. Choosing the right type of plan requires you to consider your health, your preferred network of service providers, and how you’d like to manage costs between monthly premiums and out-of-pocket expenses.

PPO

A Preferred Provider Organization (PPO) plan refers to a health insurance plan that provides maximum benefits for in-network services, but still provides coverage for out-of-network visits. With a PPO plan, you do not have to commit to a PCP, and you can visit various health providers and specialists without a referral. PPOs offer individuals the most freedom and flexibility with their service providers and generally have higher premiums than other health plans.  

POS

A Point of Service (POS) plan is a type of health insurance plan that provides different benefits depending on whether members use in-network or out-of-network healthcare providers. Similar to EPO plans, POS health plans require members to choose a designated PCP and get referrals before visiting specialists. The difference, however, is that members have the choice to use doctors, hospitals, and service providers outside of their provider network. POS plans will partially cover out-of-network visits but members will have to make higher copayments for services.

HMO

A Health Maintenance Organization (HMO) plan is a health insurance plan which offers quality care for low costs. Members pay a monthly premium for medical services from a specific provider network. With an HMO plan, you are limited to in-network providers and will not be provided coverage for medical visits outside of the network. HMO plans require individuals to choose a PCP, through whom they must coordinate all medical care and receive referrals to see specialists.

Why Should You Choose an EPO Plan?

An EPO plan is right for you if you want lower premiums, no referrals, and are comfortable visiting the service providers within your network. Those considering an EPO plan should not expect to receive special medical treatment while on this plan, whether it’s for existing medical conditions, chronic illnesses, or fertility services. 

Finding The EPO Plan That’s Ideal For You

The costs and benefits covered by EPO plans will vary depending on the region and state you live in. EPO plans can be found through the online Marketplace during the Open Enrollment Period (November-December). You may also apply for Special Enrollment if you are eligible. Use our online form to get a personalized quote and compare your plan options.

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