Exclusive Provider Organization (EPO) health plans offer a local network of providers and hospitals from which members can choose to receive care. EPOs generally have lower monthly premiums than PPO plans but members cannot receive covered care outside of their plan’s work with the exception of an emergency. EPO health insurance can be an excellent addition to an employee benefits package. However, it is important for business owners to understand how EPO insurance works and coverage terms.
How Does An EPO Health Insurance Plan Work?
Under an EPO health insurance plan, the insurance company will only provide cost-sharing when a member uses a provider or hospital inside the plan’s network. Any health care services received by providers or facilities outside of the network are not usually eligible for payments with few exceptions.
There are certain features of an EPO health insurance plan that are important to understand to ensure that the business makes the right decision.
No Primary Care Physician Required
Most EPO plans do not require members to select a primary care physician (PCP). This gives patients more freedom to see whichever providers they would like to without having to contact the insurance company to switch PCPs. However, choosing a PCP can be beneficial, especially for members who suffer from a chronic illness or a medical condition that requires continuous monitoring.
EPO health insurance plans have evolved in recent years and there are some plans that do require members to choose a PCP so it is important for members to carefully review their insurance plan.
Visit Specialists Without Referrals
Most EPOs also do not require members to get a referral from their PCP to see a specialist. This means that members can contact specialists directly to book appointments instead of first seeing their primary care provider which can extend the wait time.
Of course, there are some exceptions and certain insurance companies may require members to consult with their PCP before seeing a specialist. A PCP will usually be familiar with the specialists in that community and can provide guidance as to which specialists are best suited to handle the patient’s medical concerns.
No Claim Filing Necessary
EPO insurance plans are fairly low maintenance as members are not required to file claims themselves. All health care services are provided in-network which means that the in-network healthcare provider will automatically bill the EPO health plan for any medical services that the member receives. Under EPO insurance, members are only responsible for paying their copayment, coinsurance and deductible.
Lower Cost-Sharing Requirements Than PPO Insurance
Cost-sharing refers to an arrangement in which the insurance company and member each pay for a portion of services. The member’s portion of cost-sharing may include copayments, coinsurance and/or deductibles. EPO insurance generally has lower cost-sharing requirements compared to PPO insurance. Due to the lower cost-sharing expenses, an EPO is often considered one of the most economical choices of health insurance.
Pre-Authorization Is Needed for Some Services
EPO plans generally require members to gain authorization before undergoing certain procedures or treatments, particularly costly health services. Examples of services that may require preauthorization include CT and MRI scans, surgeries and medical equipment. If a member fails to get pre-authorization, the insurance company may refuse to pay the bill and it then becomes the responsibility of the member.
Services that require preauthorization are usually elective and do not include emergency services. Preauthorization helps to keep the cost of EPO plans down.
In-Network Providers Are Required For EPO Coverage
The most important aspect of EPO insurance refers to who a member can and cannot see under the plan. Each EPO has a list of healthcare providers that is referred to as a provider network.
A typical provider network includes hospitals, pharmacies, doctors, specialists, speech therapists and other health services. Members under an EPO plan can only receive health care services from in-network providers. When a member sees a provider out-of-network, the patient is usually responsible for 100 percent of the bill.
Although members are generally required to visit in-network healthcare providers to gain EPO coverage, there are certain exceptions to this rule.
Exception #1: Your EPO Plan Does Not Have An In-Network Specialist For A Specific Service
If a member lives in a rural community or in an area where specialists are sparse, there may be times when an EPO plan does not offer an in-network specialist for a specific service. When this happens, the insurance company will usually allow the member to continue seeing an out-of-network provider and will cover all or a portion of the costs.
Exception #2: You Were Seeing An Out-Of-Network Specialist Prior To Enrolling In EPO
Some patients will have an established relationship with a certain specialist prior to enrolling in an EPO. When switching to an in-network specialist would be problematic for the patient, the insurance company may allow the member to continue seeing the out-of-network specialist and provide financial coverage for any services rendered.
Exception #3: You Are Experiencing A Medical Emergency
When an emergency occurs, members may not always be near a provider or hospital that is in-network. That is why insurance companies will provide coverage to members who visit out-of-network providers or hospitals when a medical emergency occurs. Plans generally offer coverage for a wide range of emergency services, such as ambulance transportation, emergency room services, surgeries and other emergency procedures or monitoring. This coverage allows seriously injured or ill patients to go directly to the nearest ER without fear of non-coverage.
Speak to an Experienced Benefits Consultant
When comparing different health insurance options for their business, employers often choose an EPO plan to add to their employee benefits package. An EPO insurance plan can be an attractive benefit that draws in talent and helps retain existing employees. Not all EPO health insurance plans offer the same coverage terms so it is important to speak with an insurance broker to determine which plan is best suited for the business. Contact Business Benefits Group today to speak with an experienced benefits consultant.