An EPO is a health plan that stands for exclusive provider organization. It gets this name because it offers exclusive healthcare services from exclusive healthcare providers; however, the patients pay for themselves.
To cover EPO services, patients must receive medical services from healthcare providers and hospitals with whom the EPO has negotiated discounts.
It requires its members to use a network of doctors, hospitals, and other healthcare providers at all times except in the case of an emergency.
The plan specializes in the services rendered by in-network providers with lower costs for its members. It can be referred to as cost-friendly.
EPO, however, has out-of-network benefits, enabling you to pay out of your pocket for the care provided by the out-of-network providers.
They do not require referrals for specialty care and offer in-network coverage only. Continue reading this article to find out how EPO works.
How EPO Works
As earlier explained, the EPO plan has a contract with a network of doctors, hospitals, and other health professionals to provide health services to its subscribers.
It covers the minimum essential coverage for hospitalization, illness, and preventive health care; even though you are responsible for the full cost of the services, they manage the costs by limiting the care to doctors and specialists within the plan network.
It is important to note that even though you need network providers for the EPO health plan, you do not need referrals for specialist visits.
The doctors and hospitals the EPO plan works with are network providers or in-network providers, including specialists, physicians, and facilities like hospitals, labs, and urgent care centers.
Out Of Pocket Costs Required By EPO
EPO requires out-of-pocket costs from patients when they receive care from the health care providers in addition to the premium they pay. Below are some of the out-of-pocket costs:
Coinsurance: This refers to the percentage the members get to pay for some of the covered services offered by the health providers.
The price is not based on the full retail price of the service but rather on the discounted rate negotiated by the insurance company with health care providers like hospitals and doctors.
Copay: This refers to the set amount a member pays for every covered healthcare service; however, the amount to see a doctor differs from the amount to see an emergency room.
Deductible: This refers to the amount a member pays annually before the health plan shares the costs.
Premiums refer to the monthly or annual payments you must make to maintain your health coverage.
Out-of-Pocket Maximum: this refers to the combination of deductibles, copayments, and coinsurance that pays the complete cost of your EPO.
Benefits of EPO
EPO has several benefits, some of which include the following:
- You can pay lower insurance rates unlike other health plans
- You can get direct access to in-network specialists.
- It has a mid-level premium cost between HMO and PPO plans
- There is no need to select PCP to coordinate your health care needs
Does EPO Cover out-of-Network Treatment?
No, EPO does not cover out-of-network treatment however it can do it in an emergency.
In the case of a medical emergency, your EPO will cover that specific visit but it does not naturally cover other out-of-network visits.
Does an EPO plan need to get a Referral?
No, in the case of an EPO plan, you do not need to get a referral to see a specialist, as long as the specialist is in your network you need to make an appointment.
This is advantageous in cases when you have health conditions that require you to seek constant specialized care so you do not need to seek a referral from your primary care doctor.
Why Should I Choose an EPO?
EPO is an amazing choice to make especially if you wish to stick to using specific network providers, pay cheaper rates, and get direct access to in-network health specialists.
Why is the EPO Referred to as “Exclusive”?
The “e” in EPO is referred to as exclusive mostly because the coverage is strictly limited to a network of health practitioners.