For example, you can’t assume that just because a lab is down the hall from your EPO doctor’s office, it is in-network with your EPO. A type of managed care health insurance, EPO stands for exclusive provider organization. You don't have to … She has co-authored two books for the popular Dummies Series (as Shereen Jegtvig). additional information. Because of its generally lower cost-sharing and low premiums, an EPO is often one of the most economical health insurance choices. Typically, when customers pay for medical services or treatments, they will be reimbursed a certain amount of money by the provider. EPO is the acronym for Exclusive Provider Organization, an exclusive network of doctors, hospitals and other medical facilities. What Is an EPO (Exclusive Provider Organization)? Since your EPO likely doesn’t require you to have a PCP, it uses pre-authorization as a mechanism to reach the same goal: the EPO only pays for things that are truly medically necessary. Exclusive provider organization plans, or EPOs, are a form of health insurance that attempts to rein in costs by limiting insurance coverage to a select group of healthcare providers. Pick a Dental Plan to Meet Your Needs Now and in the Future. Check out our tips on how to get a prior authorization request approved. With an EPO (exclusive provider organization), you have a moderate amount of freedom to choose your health care providers. In an EPO health plan, you can only get health care services from in-network providers. An EPO is a health insurance option similar to a PPO (Preferred Provider Organization) but with less flexibility. Reviewed ", From: Our EPO plans are only available in Northeastern Pennsylvania, Western Pennsylvania, Central Pennsylvania and the Lehigh Valley, and Delaware. This year, HMOs and PPOs dominated the plans offered by insurers on the health insurance … Here's an example of an EPO plan, offered in Colorado by Cigna, that does require members to have a PCP. Like a PPO, you do not need a referral to get care from a specialist. In California, health insurance plan options primarily include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). This tool does not provide medical advice. Your EPO will likely require you to get permission for some services, especially those which are most costly. EPO Health Insurance—What It Is and How It Works Point of Service (POS) POS plans resemble HMOs but are less restrictive in that you’re allowed, under certain circumstances, to get care out-of-network as you would with a PPO. Don't assume anything based simply on whether the plan is an EPO, PPO, POS, or HMO! An EPO is a type of health insurance plan that offers a local network of doctors, specialists and hospitals in your area for you to choose from. HDHPs make up about one-third of employer-sponsored plans and are seen as a lower-cost health insurance option for employers over the past decade. And just like the "rule" about EPOs not requiring you to have a PCP, referrals can be a grey area too. 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. She's held board certifications in emergency nursing and infusion nursing. Under the terms of the. In return, the customers get to access the network of medical facilities and doctors for a discount. Usually, it takes a few days. Occasionally, you’ll have the authorization before you even leave the doctor’s office. Like HMOs, EPOs cover only in-network care, but networks are generally larger than for HMOs. © 2005 - 2019 WebMD LLC. and POS plans. If you think you may have a medical emergency, immediately call your doctor or dial 911. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. Pre-authorization takes time. Its principle difference is that the members must use network resources to get insurance coverage … The EPO is an important type of healthcare network. An EPO (Exclusive Provider Organization) insurance plan is a network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers.Basically, an EPO is a much smaller PPO. EPOs have some traits in common with HMOs and some traits in common with PPOs. You can get an EPO plan on your own by purchasing individual coverage through a broker, agent, or through the health insurance marketplace (also called the health insurance exchange). Pre-authorization helps your EPO keep costs down by making sure you really need the services you get. Keep your EPO in the loop. Exclusive Provider Organization (EPO) Plan A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an … An Exclusive Provider Organization, or EPO, is a type of health insurance plan in which members must utilize doctors and providers within the EPO network, except in case of a medical emergency. What type of health insurance plan should I get? HMO stands for Health Maintenance Organization, and EPO stands for Exclusive Provider Organization. by 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. So the only real "rule" is that you need to pay close attention to the specific details for your own plan. The services which require authorization are elective and not emergency services though, so a small time delay will not be life-threatening. It is intended for general informational purposes only and does not address individual circumstances. There is also a third option, Exclusive Provider Organization (EPO), which is growing in popularity in California. From the WebMD Archives. You have to check. Many plans contain co-pays before the deductible (co-pays are your friend BEFORE the deductible). EPO stands for "Exclusive Provider Organization" plan. In plans like HMOs that require you to have a primary care physician, your PCP is responsible for making sure you really need the services you get. While many insurance plans are either HMOs or PPOs, there is a third type of insurance called an EPO. It’s ultimately your responsibility to know which providers are in-network with your EPO. Have you considered enrolling in an EPO health plan? Understanding Point-of-Service Plans in Health Insurance. If you see a provider that's not on your plan’s list – other than in an emergency – you'll have to pay the full cost yourself. See At the same time, this can sometimes be a challenge in that you are limited to certain specialists within your network. How do Medigap plans help me pay for what Medicare doesn't cover? You’ll just be responsible for paying your deductible, copayment, and coinsurance. They may or may not require referrals from a primary care physician. EPO Plan Highlights: Generally pay nothing for in-network preventive care Must use in-network providers in order to receive benefits; the only out-of-network costs that will be paid are those charged as a result of receiving emergent care and POS plans, Exclusive Provider Organization (EPO) plan, Four States Start 2020 with New Surprise Billing Laws. America's Essential Hospitals. But the "rules" for primary care (and referrals, as discussed below) under EPOs, HMOs, PPOs, and POS plans have evolved a bit over time, and tend to be somewhat fluid. HMO, PPO, EPO, POS – How Do They Differ and Which Should You Choose? ", The Henry J. Kaiser Family Foundation. Your EPO’s Summary of Benefits and Coverage should tell you more about the pre-authorization requirement, but you should expect that any expensive service will need to be pre-authorized. EPO is one of the most common types of health insurance plans offered by employers. “Health Reform FAQs: Marketplace Eligibility, Enrollment Periods, Plans and Premiums.”, Society for Human  Resource Management: “For 2015, Higher Limits for HSA Contributions and Deductibles.”, Life and Health Insurance Foundation for Education: "What are the Different Types? Most require pre-authorization for things like MRI and CT scans, expensive prescription drugs, surgeries, hospitalizations, and medical equipment like home oxygen. That's partly because an EPO contracts exclusively with specific doctors, hospitals and other health care providers to form a network. June 15, 2020, Medically With an EPO (exclusive provider organization), you have a moderate amount of freedom to choose your health care providers. With Aetna's Exclusive Provider Organization (EPO) plans, you can give your employees an easy way to get care, while saving on benefits costs with an exclusive network. By Michelle Andrews. on, Different Types of Health Plans: How They Compare. But similar to PPO plans, EPO plans do not require referrals to specialist doctors, and will pay as long as the doctor is on the EPO network list. You don't have to get a referral from a primary care doctor to see a specialist. If you’re in the middle of a complex course of specialty treatment when you become an EPO member, and your specialist isn’t part of the EPO. Every EPO has a list of health care providers called a provider network. One of the most significant advantages to an EPO is participants don’t need a referral from a primary care physician to see a specialist. Four States Start 2020 with New Surprise Billing Laws. EPO stands for “Exclusive Provider Organization”. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. It works in Medicare as well as Marketplace health insurance. Make sure to read your health insurance policy very carefully. Customers can contract with an insurance company and pay premiums to them. out-of-network providers The doctors, hospitals, labs, and other health care providers who DO NOT have a contract with a health insurance company. Provider networks change. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency). If you make that assumption and you’re wrong, you’ll have to pay the entire mammogram bill yourself. Shereen Lehman, MS, is a healthcare journalist and fact checker. It is a type of health plan that provides a local network of doctors and hospitals for you to choose from. ... State laws and regulations governing health insurance and health plans may vary from state to state. What is an EPO? Providers are independent contractors and are not agents of Aetna. When you do not need a … Also note that there are no out-of-network benefits under an EPO health insurance plan. January 22, 2020. There are no hard-and-fast rules when it comes to cost-sharing in the various types of health plans. Your EPO will decide whether or not you may finish the course of treatment with your current physician on a case-by-case basis. Sarah Goodell Why will you look for an EPO health insurance plan? A provider network can be made up of doctors, hospitals and other health care providers and facilities that have agreed to offer negotiated rates for services to insureds of certain medical insurance plans. 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. EPO plans differ as to what types of services must be pre-authorized. 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. You can think of that as a trade-off for the fact that the EPO limits you to only using in-network medical providers, whereas PPOs will cover a portion of your costs even if you see out-of-network providers. As a member of an EPO, you can use the doctors and hospitals within the EPO network. Exclusive provider organization plans (EPO) PPOs are the most common type of health plan in the employer-sponsored health insurance market, while HMOs lead the way in the individual insurance market. An exclusive provider organization (EPO) health insurance plan offers the cost savings of an HMO with the flexibility of a PPO. For services to be covered, you have to receive medical services from doctors and hospitals with whom the EPO has negotiated discounts, although there's an exception for emergency care. If you’re having a stroke, heart attack, or another true emergency you should go to the nearest emergency room whether or not it’s in-network with your EPO. Different Types of Health Plans: How They Compare. Your employer may offer an EPO plan as one of your insurance coverage options. As an EPO member, you cannot go outside your plan’s network for care. A type of managed care health insurance, EPO stands for exclusive provider organization. EPO insurance plans offer a very limited number of providers who offer large discounts on their rates. ", Minnesota Medicine, February 2011: "Five Payment Models: The Pros, the Cons, the Potential. What is an EPO and how does it work? Enrollment in Oscar depends on contract renewal. A health plan's network is the set of healthcare providers — e.g., hospitals, doctors, and specialists — with whom the insurance company has contractual agreements in any given plan year. Accidentally getting out-of-network care can be a very expensive mistake when you have an EPO. Well, there are several technical differences between HMO and EPO. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. How does Medicare Advantage (Part C) help me pay for what Medicare does not cover. Although your doctor may volunteer to get pre-authorization for you, it’s ultimately your responsibility to make sure you get a service pre-authorized before you receive the health care. An EPO health plan's rules center around two basic cost-containment techniques: What do you need to know about using your EPO health insurance? Gontscharow, Zina. HMO, PPO, EPO: What Health Plan Is Best? If you get care out-of-network, the EPO won’t pay for it; you’ll be stuck paying the entire bill yourself. Your in-network health care provider bills your EPO health plan directly for the care you receive. An EPO (or “exclusive provider organization”) is a bit like a hybrid of an HMO and a PPO. If a particular service requires pre-authorization (prior authorization) and you don’t get it, your EPO can refuse to pay. When considering their difference, the HMO can be termed as an insured product , which means that the insurance company will pay the costs of the claim. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Exclusive Provider Organization (EPO) plan. What if you already have EPO health insurance? All rights reserved. Both types of insurance use a system in which medical facilities, doctors and an insurance company work together. 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