What Are Exclusive Provider Organization (EPO) Plans: Key Features Of EPO Plans
An EPO (Exclusive Provider Organization) plan is a managed care health insurance plan where you can get your medical care exclusively from the provider’s network. The insurance providers for these plans have an extensive network of doctors, hospitals, and other medical care providers. These plans do not offer coverage if the policyholder gets treatment outside the network, except for emergencies.
Like HMO (Health Maintenance Organization) plans, EPO insurance policies require you to select a primary care physician (PCP). This is a doctor who provides you with preventive care and treatment for minor/chronic illnesses. However, you do not need to get a referral from a PCP to see a specialist, unlike HMO plans.
How Does EPO Plans Work
Insurers negotiate terms with healthcare providers to create a provider network for EPO insurance. Each network offers a comprehensive range of healthcare services via hospitals, pharmacies, x-ray facilities, healthcare providers, labs, specialists, speech therapists, and more.
Whenever you need healthcare services, you need to check the current list of in-network providers. If you get healthcare out-of-network, you may find yourself having to foot the entire bill. Thus, accidentally getting out-of-network care can prove to be a costly mistake.
There are three distinct exceptions to the in-network requirement. These are:
- If your EPO plan does not have a specialist providing a particular healthcare facility, you can pre-arrange out-of-network care with the insurer.
- You can get out-of-network care if you are in the middle of a complex treatment when you opt for an EPO insurance plan. Your EPO may let you finish the treatment with the current doctor on a case-by-case basis.
- If you experience a true emergency like a stroke or a heart attack, you may go to the nearest emergency room. In this case, EPOs will cover the cost of emergency care received at the nearest out-of-network facility.
Key Features of EPO Plans
The key features of EPO plans are as follows:
- The insurance provider doesn’t cover out-of-network costs
- Pre-authorisation is required if you wish to visit an out-of-network healthcare provider
- You need to select a primary healthcare provider
- One doesn’t have to submit a referral for the insurance provider to cover specialist visits
Difference Between EPO, PPO, and POS Plans
Besides EPO, PPO (Preferred Provider Organisation) and POS (Point of Service) are two other popular managed care plans. The following is a brief comparison between these health plans:
| Type of plans | EPO | PPO | POS |
| Meaning | In an EPO plan, you have to get treatment from a network of providers on a list. | This has a higher premium than PPO and POS plans. It covers both in-network and out-of-network costs. | This is a hybrid of HMO and PPO plans, covering some of the costs of out-of-network treatment. |
| PCP required | Usually required | Not required | Required |
| Pre-authorisation required | Usually yes | No | Usually yes |
| Premium costs | Moderate | Higher | Moderate |
| Out-of-network coverage | Not covered (except for emergencies) | Covered, but at slightly higher costs | Cover but at higher costs |
Limitations of an EPO Plan
Enumerated below are the limitations of an EPO plan:
- EPO premiums are low but deductible and coinsurance are applicable.
- You need to avail healthcare within the EPO network itself. If you avail care outside the network, EPO will not cover the expenses.
Costing of an EPO Plan
The cost of an EPO plan is dependent upon the terms and conditions of the plan and the place where one lives.
One should check and compare out-of-pocket limits, deductibles and coinsurance of the EPO plan.
How to Choose the Best EPO Insurance Plan for Yourself
Take a look at the pros and cons of each health insurance plan to pick the best one.
1. EPO plans
- Pros: These provide great flexibility in choosing providers as long as they are in-network. EPO plans have lower premium costs, require no referrals to visit specialists and settle bills directly with doctors and hospitals.
- Cons: These insurance policies do not cover the costs of treatments taken out of the network. So, you will have to make sure that the doctors you go to are in-network.
2. PPO plans
- Pros: These provide you with the most freedom to choose doctors and specialists as they cover out-of-network costs. It also lets you see specialists without the need for a referral.
- Cons: These plans usually carry high premiums and sometimes require high-cost sharing. Lately, PPO providers have reduced the size of networks as they have switched to other plans.
3. POS plans
- Pros: POS plans are more flexible than EPOs as they offer more leeway to see out-of-network doctors and providers. They provide this benefit despite having the same moderate costs as EPO plans.
- Cons: Though POS lets you visit out-of-network doctors, you will have to pay more out of your pocket to do so. Moreover, they do not let you see specialists without referrals from your PCP.
Things to Know about EPO Plans before Investing in them?
Given below are a list of things that one needs to remember about EPO plans before investment:
- You need to pay premiums for the maintenance of insurance.
- You need to pay a specified amount as a deductible till the time the EPO plan starts covering the costs. You only need to pay copayment or coinsurance after completing the payment of deductibles.
- You need to pay coinsurance after paying deductibles.
- Then, you need to pay copays, i.e, a fixed amount, for the covered services.
- You also need to pay the out-of-pocket maximum before your EPO starts covering all your costs.
Reasons to Buy an EPO Plan
Given below are the reasons why one should buy an EPO plan:
- EPO plans are beneficial because it provides direct access to in-network specialists.
- In case of a medical emergency, EPO plans act as saviours because people can receive assistance from both in-network and out-of-network healthcare providers.
- Interest rates for EPO insurances are lower than plans like PPOs.
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Final Word
EPO (Exclusive Provider Organization) plans are a good choice if you do not mind a limited provider network for the benefit of low insurance premiums. It provides enough providers for routine healthcare and the ability to consult a specialist without the need for referrals.
These insurance policies are available in countries like the United States and not in India. Those who are looking for an affordable health insurance policy here can opt for Navi’s Health Insurance. Simply download the Navi Health Insurance app from Google Play Store to get a health plan providing cashless treatment via 10,000+ hospitals in the country.
FAQs
Ans: No. In an EPO plan, the provider takes all responsibility for your healthcare. The healthcare providers (doctors, hospitals, etc.) will file your bills directly to the insurer, who will settle them directly.
Ans: Cost-sharing refers to the portion of costs that you and the insurance company will bear. EPOs usually tend to have lower cost-sharing portions for the insured, making them quite economical.
Ans: EPO providers have a pre-authorisation requirement for expensive treatments and medications to keep costs low and ensure that their plans cover only necessary things. CT scans, MRI scans, expensive surgeries, prescription drugs and hospitalisations are some things that require pre-authorisation.
Ans: Your doctor will ask your insurer for prior approval on certain treatments/medications. This may take some time, from a few hours to weeks (in case of problems). You should check your health plan and take responsibility to get a service pre-authorised.
Ans: EPO plans generally require moderate premiums, though the exact costs vary depending on your residence and specific policy. Before choosing a policy, make sure to check the co-insurance, deductibles and out-of-pocket maximums.
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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.
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