EPO health insurance: what it is and how it works


Have you considered participating in an EPO health plan? If so, it is important to understand exactly what these plans are and how they work to ensure that the plan is tailored to your needs.

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What if you already have EPO health insurance? Understanding the complexities of how your EPO works can help you use your health plan effectively and avoid costly mistakes.

What is EPO (Exclusive Provider Organization)?

EPO is a type of managed care health insurance, which stands for Exclusive Provider Organization . EPO health insurance is so named because you should receive medical care exclusively from the health care providers that EPO contracts with; otherwise, the EPO will not pay for the treatment. As with other health plans that require you to stay online with your providers, EPOs will pay for out-of-network emergency services.

Like their PPO and HMO cousins, EPO health plans have cost containment rules for how you receive your health care. If you don't follow your EPO's rules for getting medical care, you won't pay for your treatment.

The EPO health plan rules are based on two main cost containment methods:

  1. To cover services, you must obtain health care services from health care providers and hospitals with whom the EPO has negotiated discounts, although there is an exception for emergency care.
  2. Medical services are limited to things that are medically necessary or that lower your long-term health care costs, such as preventive services .

How does EPO health insurance work?

What do you need to know about using your EPO health insurance? Be sure to read your health insurance policy carefully. By staying online and pre-authorizing when needed, you can save a lot of money. Let's take a look at the most important concepts to understand.

You must use intranet providers

Each EPO has a list of health care providers called a provider network . This network offers every type of healthcare imaginable, including healthcare providers, specialists, pharmacies, hospitals, labs, X-ray rooms, speech therapists, home oxygen, and more.

In an EPO health plan, you can only get care from network providers . If you receive care outside of the network , the EPO will not pay for it; you will have to pay the entire bill yourself. Accidentally getting help offline can be a very costly mistake if you have an EPO.

Ultimately, you need to know which providers are in your EPO's network. For example, you can't assume that just because the lab is down the hall from your EPO's office, it's in line with your EPO. You should check it out. Likewise, don't assume that the imaging center that performed your mammogram last year is still in line with your EPO this year. Provider networks are changing. If you make this assumption and get it wrong, you will have to pay the bill for the mammogram in full.

There are three exceptions to the in-network requirements:

  1. If the EPO does not have a provider in the network for the specialty services you need. If this happens to you, make arrangements in advance for out-of-network specialty care at the EPO. Keep your EPO up to date.
  2. If you are going through a difficult course of specialized treatment when you become a member of the EPO and your specialist is not part of the EPO. Your EPO will decide if you can complete treatment with your current healthcare provider on an individual basis.
  3. For real emergencies. If you have a stroke, heart attack, or other serious situation, you should go to the nearest emergency room, whether or not you are in line with your EPO. Under the Affordable Care Act , health plans must cover the cost of emergency care received at the closest out-of-network facility, as if it were in-network care. However, if you need to get to a hospital from an emergency department, your EPO may ask an out-of-network emergency department to transfer you to a network hospital for admission. And it's important to understand that even if your health plan covers out-of-network emergency care as if it were in-network, they will only pay what they think is reasonable and normal . But out-of-network emergency department and health care providers do not have a contract with your insurance company, which means they are not required to accept payment from the insurer as payment in full. They can still send an invoice unless prohibited by state regulations. More than half of the US states have rules that protect patients from balancing the accounts in an emergency. But it's also important to understand that state health insurance laws do not apply to self-insured health plans , which cover most people with employer-sponsored health insurance.

You most likely don't need a therapist

Your EPO health plan generally does not require you to have a primary care physician (PCP) , although it is a good idea to get one.

But the "rules" for primary health care (and referrals, as explained below) for EPO, HMO, PPO, and POS plans have changed slightly over time and tend to run somewhat fluid. Below is an example of an EPO plan proposed by Cigna in Colorado that requires members to have a PCP.

So the only real "rule" is that you need to pay close attention to the specifics of your own plan. It is true that most EPOs do not require you to have a PCP. But don't think yours isn't!

You probably don't need a referral to see a specialist

Most EPOs do not require you to get a referral from your primary care provider before seeing a specialist. This makes it easier to see a specialist while making the decision yourself, but you should be very careful to only see specialists who are in line with your EPO. The advantage of having a PCP is that they often know specialists from their community and most professionals have special interests within their specialty, for example, some general oncologists may have a special interest in breast cancer while others may have a special interest. with lung cancer.

And just like the 'rule' that EPO does not require you to have a treating physician, referrals to specialists can also be a gray area. Cigna Colorado EPOs that require a PCP also require a referral. So again, the most important thing is that you are familiar with the rules that apply to your particular plan, or to any plan you consider an alternative. Assume nothing based on whether the plan is EPO, PPO, POS, or HMO!

You will need to get prior authorization to receive expensive services

Your EPO may require you to authorize certain services, especially those that are the most expensive. If a particular service requires prior authorization (prior authorization ) and you do not receive it, your EPO may deny payment. The services that require authorization are optional and are not emergency services, so a small delay in time will not be life threatening.

Prior authorization helps EPO keep costs down by making sure you really want the service you receive. In plans like HMOs that require you to have a PCP, your PCP is responsible for making sure that you really need the services you receive. Since your EPO most likely does not need a PCP, it uses prior authorization as a mechanism to accomplish the same goal – the EPO only pays for things that are medically necessary.

EPO plans differ based on the types of services that must be pre-authorized. Most require prior authorization for things like MRIs and CT scans, expensive prescription drugs, surgeries, hospital stays, and medical equipment like home oxygen. Your EPO Summary of Benefits and Coverage should detail the prior authorization requirements, but you should expect any expensive services to be preauthorized.

While your provider may voluntarily give you prior authorization, ultimately, it is your responsibility to ensure that you obtain prior authorization for a service before receiving medical care. If you don't, your EPO has the right to refuse payment for medical care, even if it was medically necessary and you received it from a network provider.

Prior authorization takes time. Sometimes you will have permission before you leave the provider's office. This usually takes several days. In severe cases or if there is a problem with the authorization, this may take several weeks. Check out our tips for getting a prior authorization request approved .

No need to file a claim

If you have EPO health insurance, you don't have to fiddle with bills and claim forms because all your care is on chain. Your network provider bills your EPO health plan directly for the care you receive. You are simply responsible for paying your deductible, copayments, and coinsurance .

Cost-sharing requirements in EPO are typically lower than they would be in PPO

Cost sharing is a practice in which you and your insurance company pay for a portion of the services. Your cost sharing may include deductibles , copays , and / or coinsurance .

There are no hard and fast rules when it comes to cost sharing between different types of health plans. Some EPOs have a high cost share, while others have a low share. But overall, EPOs tend to have less cost-sharing than PPOs. You can think of this as a compromise, as the EPO limits you to only network providers, while PPOs will cover some of your costs even if you meet with out-of-network providers. Due to its lower cost sharing and lower premiums , EPO is often one of the most cost-effective health insurance options.

EPO Health Insurance Summary

EPOs share some similarities with HMOs and some similarities with PPOs. So you can think of the EPO as a cross between an HMO and a PPO – like an HMO, you must stay in the plan's network. But, as with PPOs, you generally don't need to get a referral from your premium healthcare provider to see a specialist.

Many people like the simplicity of being able to make an appointment with a specialist without consulting a therapist. At the same time, this can sometimes be a problem as you are limited to certain specialists in your network. Having an EPO also requires you to be actively involved in planning expensive services or procedures and leaves you with the primary responsibility for complying with the required pre-approvals. Overall, the combination of low premiums and low cost sharing makes EPO a good choice for many people. If comparing different plans is overwhelming, check out our HMO, PPO, EPO comparison. and POS plans .

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