", The Henry J. Kaiser Family Foundation. According to an eHealth survey, EPO plans accounted for 12 percent of all plans selected in 2018. 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. You’ll just be responsible for paying your deductible, copayment, and coinsurance. © 2005 - 2019 WebMD LLC. It’s ultimately your responsibility to know which providers are in-network with your EPO. A type of managed care health insurance, EPO stands for exclusive provider organization. Typically, but not always, you will be required to choose a Primary Care Physician or PCP. The Exclusive Provider Organization. But in general, EPOs tend to have lower cost-sharing than PPOs. EPO health insurance got this name because you have to get your health care exclusively from health care providers the EPO contracts with, or the EPO won’t pay for the care. As is the case with other health plans that require you to stay within their provider networks, EPOs will pay for out-of-network care in emergency situations. This makes it easier to see a specialist since you’re making the decision yourself, but you need to be very careful that you’re seeing only specialists that are in-network with your EPO. There are three exceptions to the in-network requirement: Your EPO health plan generally won’t require you to have a primary care physician (PCP), although getting a PCP is still a good idea. What if you already have EPO health insurance? So the only real "rule" is that you need to pay close attention to the specific details for your own plan. 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. 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. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. It is a type of health plan that provides a local network of doctors and hospitals for you to choose from. EPO rates are typically lower than other types of insurance, such as PPO plans. Sarah Goodell Make sure to read your health insurance policy very carefully. They offer a wide network of quality, patient-focused doctors, hospitals and specialists. Some health plans include coverage (at a higher cost) for out-of-network providers, and some may not provide coverage at all. Accidentally getting out-of-network care can be a very expensive mistake when you have an EPO. Typically, when customers pay for medical services or treatments, they will be reimbursed a certain amount of money by the provider. ", U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality: "Choosing a Health Plan. You don't have to … Typically, there's a lower premium than a PPO offered by the same insurer. Like a PPO, you do not need a referral to get care from a specialist. additional information. Pre-authorization helps your EPO keep costs down by making sure you really need the services you get. An EPO is usually more pocket-friendly than a PPO plan. Usually, it takes a few days. Most EPOs will not require you to get a referral from a primary care doctor before seeing a specialist. 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. Pre-authorization takes time. Discover What a PPO Is and How It Can Work for You, A Provider Is a Fancy Way of Saying Doctor... and Much More, Asking for a Network Gap Exception When No In-Network Providers Nearby, What You Need to Know Before Getting Out-Of-Network Care, Best Short-Term Health Insurance Companies of 2021, How Referrals Work With Your Health Insurance, 7 Health Insurance Concepts You Need to Understand, Reasons for Health Insurance Claim Denials and What You Should Do. When … out-of-network providers The doctors, hospitals, labs, and other health care providers who DO NOT have a contract with a health insurance company. In California, health insurance plan options primarily include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). If this happens to you, prearrange the out-of-network specialty care with the EPO. At the same time, this can sometimes be a challenge in that you are limited to certain specialists within your network. How do I get back on my parents' health coverage? Don't assume anything based simply on whether the plan is an EPO, PPO, POS, or HMO! ", 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. Reviewed Customers can contract with an insurance company and pay premiums to them. 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. THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. An EPO is a managed care plan in which services are only covered if the patient sees a doctor, specialist or hospital within the plan’s network. HMO stands for Health Maintenance Organization, and EPO stands for Exclusive Provider Organization. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. And just like the "rule" about EPOs not requiring you to have a PCP, referrals can be a grey area too. How does Medicare Advantage (Part C) help me pay for what Medicare does not cover. So again, the most important thing is that you're familiar with the rules that apply to your specific plan, or to any plan that you're considering as an alternative. 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. Rates. There are no hard-and-fast rules when it comes to cost-sharing in the various types of health plans. An exclusive provider organization (EPO) health insurance plan offers the cost savings of an HMO with the flexibility of a PPO. 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 Insurance Plans What is an EPO plan? EPO stands for "Exclusive Provider Organization" plan. There are a number of different types of networks with HMO, PPO, EPO, and … If you think you may have a medical emergency, immediately call your doctor or dial 911. When you do not need a … Health care professionals and facilities, such as doctors and hospitals. Like HMOs, EPOs cover only in-network care, but networks are generally larger than for HMOs. Provider networks change. With an EPO (exclusive provider organization), you have a moderate amount of freedom to choose your health care providers. Oscar is an HMO with a Medicare contract. Pick a Dental Plan to Meet Your Needs Now and in the Future. What is an EPO and how does it work? What type of health insurance plan should I get? 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. Thank you, {{form.email}}, for signing up. If you are finding it mind-boggling as you compare different plans, check out our comparison of HMOs, PPOs, EPOs. Every EPO has a list of health care providers called a provider network. “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? Do You Know How Your Health Insurance Provider Network Works? ", Office of Personnel Management: "Healthcare Plan Information" and "2013 High-Deductible Health Plans with Health Savings Accounts/Health Reimbursement Arrangements. Health Insurance Explained. Our EPO plans are only available in Northeastern Pennsylvania, Western Pennsylvania, Central Pennsylvania and the Lehigh Valley, and Delaware. 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. 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. Overall, the combination of its low premiums and low cost-sharing make EPOs a good choice for many people. If you make that assumption and you’re wrong, you’ll have to pay the entire mammogram bill yourself. But like a PPO, you're usually not required to get a referral from your premium care doctor in order to see a specialist. This is in contrast to EPO (Exclusive Provider Organization) medical insurance plans, which would not cover any medical services for out-of-network provider visits at all. Understanding the ins and outs of how your EPO works will help you use your health plan effectively and avoid expensive mistakes. Read our, Jose Luis Pelaez Inc. / Blend Images / Getty Images. Health care services are limited to things that are. Your EPO will decide whether or not you may finish the course of treatment with your current physician on a case-by-case basis. What is an EPO? Also note that there are no out-of-network benefits under an EPO health insurance plan. By Michelle Andrews. on, Different Types of Health Plans: How They Compare. A type of managed care health insurance, EPO stands for exclusive provider organization. If a particular service requires pre-authorization (prior authorization) and you don’t get it, your EPO can refuse to pay. An EPO (or “exclusive provider organization”) is a bit like a hybrid of an HMO and a PPO. It works in Medicare as well as Marketplace health insurance. How Health Insurance Works When You Live in Multiple States, Here's an example of an EPO plan, offered in Colorado by Cigna, how to get a prior authorization request approved, comparison of HMOs, PPOs, EPOs. ... State laws and regulations governing health insurance and health plans may vary from state to state. How Much of Your Surgery Will Health Insurance Cover? As a member of an EPO, you can use the doctors and hospitals within the EPO network. 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? But don't assume that yours doesn't! and POS plans. EPO plans differ as to what types of services must be pre-authorized. 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. Premiums are higher than HMOs, but lower than PPOs. The services which require authorization are elective and not emergency services though, so a small time delay will not be life-threatening. 6/15/2020, Fair Health, Inc.: "Alphabet Soup of Health Plans" and "Understanding High-Deductible Health Plans. What is an EPO Plan? EPO Health Insurance—What It Is and How It Works, Ⓒ 2021 About, Inc. (Dotdash) — All rights reserved. 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. Members of the EPO only have coverage for care provided within the CDPHP network. 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. Most require pre-authorization for things like MRI and CT scans, expensive prescription drugs, surgeries, hospitalizations, and medical equipment like home oxygen. on 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. EPO No-deductible health insurance with provider options This plan offers greater flexibility of health care providers similar to the PPO plan. 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. This managed care health plan comprises a network of health care providers that the EPO contracts with at negotiated rates. 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. You Likely Don't Have to Have a Primary Care Physician, You Likely Don't Need to Have a Referral to See a Specialist, You Will Be Required to Get Pre-Authorization for Expensive Services, Cost-Sharing Requirements in an EPO are Generally Lower Than They Would Be in a PPO. HMO, PPO, EPO: What Health Plan Is Best? EPO is one of the most common types of health insurance plans offered by employers. 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. Under the terms of the. Exclusive Provider Organization (EPO) plan. Some EPOs have high cost-sharing, while others have low cost-sharing. January 22, 2020. Its principle difference is that the members must use network resources to get insurance coverage … 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. If you don’t, your EPO has the right to refuse to pay for the care, even if the care was medically necessary and you got it from an in-network provider. Your in-network health care provider bills your EPO health plan directly for the care you receive. All rights reserved. WebMD does not provide medical advice, diagnosis or treatment. 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. EPO stands for “Exclusive Provider Organization”. Many plans contain co-pays before the deductible (co-pays are your friend BEFORE the deductible). An advantage of having a PCP is that they are often familiar with the specialists in your community, and most specialists have special interests within their specialty, for example, some general oncologists may have a special interest in breast cancer whereas another may have a special interest in lung cancer. It is intended for general informational purposes only and does not address individual circumstances. Elizabeth Davis, RN, is a health insurance expert and patient liaison. The EPO is an important type of healthcare network. Deductible vs. Copayment: What's the Difference? 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. As an EPO member, you cannot go outside your plan’s network for care. 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 Here's an example of an EPO plan, offered in Colorado by Cigna, that does require members to have a PCP. See Providers are independent contractors and are not agents of Aetna. How do Medigap plans help me pay for what Medicare doesn't cover? 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. 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). The Cigna EPO in Colorado that requires PCPs also requires referrals in order to see a specialist. Understanding Point-of-Service Plans in Health Insurance. While many insurance plans are either HMOs or PPOs, there is a third type of insurance called an EPO. When deciding which type of health insurance plan … Enrollment in Oscar depends on contract renewal. Staying in-network and getting pre-authorizations when needed could save you a lot of money. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Coronavirus in Context: Interviews With Experts, Sign Up to Receive Our Free Coroanvirus Newsletter, Medically These plans are among the most affordable options with generally low monthly rates. This network offers every imaginable type of health care service including doctors, specialists, pharmacies, hospitals, labs, x-ray facilities, speech therapists, home oxygen, and more. They may or may not require referrals from a primary care physician. Healthcare.gov. That's partly because an EPO contracts exclusively with specific doctors, hospitals and other health care providers to form a network. An EPO, or Exclusive Provider Organization, is a type of health plan that offers a local network of doctors and hospitals for you to choose from. In an EPO health plan, you can only get health care services from in-network providers. Occasionally, you’ll have the authorization before you even leave the doctor’s office. 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. by She's held board certifications in emergency nursing and infusion nursing. 7  Like HMOs, many POS plans require you to have a PCP referral for all care whether it’s in or out-of-network. Four States Start 2020 with New Surprise Billing Laws. Well, there are several technical differences between HMO and EPO. An EPO is a health insurance option similar to a PPO (Preferred Provider Organization) but with less flexibility. EPOs have some traits in common with HMOs and some traits in common with PPOs. However, there are no deductibles or co-insurance. Shereen Lehman, MS, is a healthcare journalist and fact checker. With an EPO (exclusive provider organization), you have a moderate amount of freedom to choose your health care providers. Different Types of Health Plans: How They Compare. An EPO is an Exclusive Provider Organization and is an example of a managed care plan. Both types of insurance use a system in which medical facilities, doctors and an insurance company work together. Have you considered enrolling in an EPO health plan? HMO, PPO, EPO, POS – How Do They Differ and Which Should You Choose? Read on to learn more! Let's look at the most important concepts to understand. 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 … Cost-sharing is a practice in which both you and your insurance company pay for a portion of services. An Exclusive Provider Organization (EPO) is a lesser-known plan type. If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan. There is also a third option, Exclusive Provider Organization (EPO), which is growing in popularity in California. 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. on Why will you look for an EPO health insurance plan? June 15, 2020, Medically For true emergencies. In return, the customers get to access the network of medical facilities and doctors for a discount. If you get care out-of-network, the EPO won’t pay for it; you’ll be stuck paying the entire bill yourself. Your employer may offer an EPO plan as one of your insurance coverage options. It's true that most EPOs don't require you to have a PCP. Gontscharow, Zina. 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. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. 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. If the EPO doesn’t have an in-network provider for the specialty service you need. Like their cousins, PPOs and HMOs, EPO health plans have cost-containment rules about how you get your health care. Likewise, don’t assume that the imaging facility that did your mammogram last year is still in-network with your EPO this year. EPOs generally offer a little more flexibility than an HMO and are generally a bit less pricey than a PPO. Reviewed Reviewed From the WebMD Archives. 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. This includes access to a national network of 825,000+ providers of care. This summary offers highlights but does not detail all benefits, limitations, or exclusions. What Is an EPO (Exclusive Provider Organization)? America's Essential Hospitals. If you don’t follow your EPO’s rules when you get health care services, it won't pay for the care. 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. 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. Your insurance will not cover any costs you get from going to someone outside of that network. Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Contact an Aetna rep. ... Health benefits and health insurance plans contain exclusions and limitations. Under EPO health insurance plans, you will not receive any coverage out-of-network. Check out our tips on how to get a prior authorization request approved. Keep your EPO in the loop. In bad cases, or if there’s a problem with the authorization, it can even take weeks. ", Minnesota Medicine, February 2011: "Five Payment Models: The Pros, the Cons, the Potential. and POS plans, Exclusive Provider Organization (EPO) plan, Four States Start 2020 with New Surprise Billing Laws. 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. EPO insurance plans offer a very limited number of providers who offer large discounts on their rates. But there's no coverage for out-of-network providers. Your EPO will likely require you to get permission for some services, especially those which are most costly. An Exclusive Provider Organization (EPO) health insurance plan requires you to use the doctors and hospitals within its own network, much like a Health Maintenance Organization (HMO). Many people like the ease of being able to schedule an appointment with a specialist without consulting a primary care physician. This tool does not provide medical advice. You have to check. This year, HMOs and PPOs dominated the plans offered by insurers on the health insurance … She has co-authored two books for the popular Dummies Series (as Shereen Jegtvig). Because of its generally lower cost-sharing and low premiums, an EPO is often one of the most economical health insurance choices. EPO is the acronym for Exclusive Provider Organization, an exclusive network of doctors, hospitals and other medical facilities. Your portion of the cost-sharing can includ deductibles, copayments, and/or coinsurance. You don't have to get a referral from a primary care doctor to see a specialist. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency). PPO, or Preferred Provider Organization, health plans are generally more flexible than EPO (Exclusive Provider Organization) plans and have higher premiums.This comparison explains how. Will not receive any coverage out-of-network how does it work leave the doctor ’ s network care... Savings Accounts/Health Reimbursement Arrangements savings Accounts/Health Reimbursement Arrangements / Getty Images facilities and doctors for discount! Does n't cover than an HMO and a PPO offered by the provider access network. At a higher cost ) for out-of-network providers, and some traits in common HMOs!, hospitals and other medical facilities and are generally larger than for HMOs `` 2013 health... You will be reimbursed a certain amount of freedom to choose your health insurance EPO! With health savings Accounts/Health Reimbursement Arrangements when it comes to cost-sharing in the various types health! Are finding it mind-boggling as you compare different plans, check out our tips on how to get from... By the same insurer PPOs, there 's a lower premium than a PPO immediately call doctor., they will be reimbursed a certain amount of money by the same time, this sometimes... Ease of being able to schedule an appointment with a specialist read our, Jose Luis Pelaez Inc. Blend! Be responsible for paying your deductible, copayment, and some traits in common with HMOs some. In order to see a specialist ins and outs of how your EPO will decide whether not! A Dental plan to Meet your Needs Now and in the various types of services must be pre-authorized plans are! One of the most affordable options with generally low monthly rates have some traits common... Of the most important concepts to understand reimbursed a certain amount of freedom to choose a primary care physician PCP. Much of your Surgery will health insurance, such as doctors and hospitals for to... Wide network of 825,000+ providers of care specialty service you need to pay is intended for general informational purposes and! Plans accounted for 12 percent of all plans selected in 2018 many insurance plans are the... 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Members to have a medical emergency, immediately call your doctor or dial 911 EPOs cover only in-network care but! Are most costly emergency, immediately call your doctor or dial 911 epo health insurance seeing. Often one of your insurance coverage options the Cons, the combination of its low premiums an. Insurance provider network works nursing and infusion nursing last year is still in-network with your will... Payment Models: the Pros, the combination of its generally lower cost-sharing and low cost-sharing EPOs... Of money for `` Exclusive provider Organization ( EPO ) plan, you can not go outside your ’! Look for an EPO ( Exclusive provider Organization ” ) is a third type of health insurance for... Help me pay for what Medicare does not detail all benefits, limitations, or exclusions your. Hmo stands for health Maintenance Organization, an Exclusive provider Organization happens to you, the! 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