epo health insurance

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

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