There are many benefits of finding an EPO health plan that works for you, but do you really know the ins and outs of the type of coverage?

What is an EPO Plan?

An EPO, which stands for Exclusive Provider Organization, refers to the network of healthcare providers within a health insurance plan that is committed to working with and is responsible for compensating a certain amount for your care.

When enrolled in an EPO plan, your insurer will provide cost sharing when you use a health care provider such as doctors, hospitals and imaging services that are within your network. This means that whatever type of care you accept outside of your network will not be qualified for payments through your insurance provider.

The only exemption to these restrictions is in the case of an emergency, as Insurers acknowledge that there are instances where care is vital, and insurance purchasers most likely will not have a choice as to where the care is provided. An excellent example of this situation is when an ambulance is called, and they take you to the nearest hospital.

There are also guidelines that have been set by Obama’s Affordable Care Act, that come into play with EPO plans. Insurance groups are required by law to handle out of network emergency care in the same way as in-network care.

For example, if you need critical medical attention within an emergency room, your plan has to provide you with the same cost-sharing structure for both in-network and out-of-network assistance.

What Are the Differences Between an EPO Plan and an HMO Plan?

In a way, EPO and HMO plans are quite similar. Like an EPO, Health Management Organization (HMO) plans also limit clients to an existing set of providers. However, under an HMO, the policyholder has to choose a primary care doctor that is their first point of contact for all of the care they receive.

This means that if you would like to visit with a specialist or have any type of aid, you need to get a referral from your primary physician. Those with an EPO plan have the freedom to see specialists without referrals.

This right, however, comes with its own set of compromises. Because EPO policyholders are allowed to choose their own specialists and hospitals to receive care, they need to make sure that they are within the network of providers listed within their plan.

The price of out of network care is not available for any cost sharing or out of pocket maximums given by your EPO insurer. One situation many users face is that they will begin a medical service, such as surgery in an in-network hospital, but one of the doctors involved in the pre/during/post care is not in the network.

What Is Pre-Authorization Within An EPO Plan?

The other compromise is a type of cost-saving requirement used by insurance companies called pre-authorization. While you will be able to utilize the care of specialists and service providers, your insurance company can require you to get consent before they compensate you for their part of the medical procedure. This is a common practice for high-cost services such as operations, MRIs and prescriptions.  

Know that it is your responsibility to request this type of approval before receiving any kind of care. If you don’t, you can be on the hook for the cost!

Now that you know a little more about EPO health plans contact our team of qualified Insurance professionals to find the policy that best suits your needs. Call us today at 1-844-903-3838.