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.
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:
The key features of EPO plans are as follows:
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|
|Out-of-network coverage||Not covered (except for emergencies)||Covered, but at slightly higher costs||Cover but at higher costs|
Enumerated below are the limitations 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.
Take a look at the pros and cons of each health insurance plan to pick the best one.
Given below are a list of things that one needs to remember about EPO plans before investment:
Given below are the reasons why one should buy an EPO plan:
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.
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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