What Is EPO Insurance?

Are you wondering what EPO insurance is? You have come to the right place. Continue reading to find out.

What is EPO insurance? EPO means “Exclusive Provider Organization” plan. As a part of an EPO, you can utilize the specialists and medical clinics inside the EPO network, yet can’t go outside the organization for care. There are no out-of-network benefits. A well overseen care plan where administrations are covered just in the event that you go to doctors, specialists or clinics in the arrangement’s organization (besides in a crisis). With an EPO (exclusive provider organization), you have a moderate measure of opportunity to pick your medical care suppliers. You don’t need to get a reference from an essential consideration specialist to see a master. Regularly, there is a lower premium than a PPO offered by a similar back up plan. Yet, there is no inclusion for out-of-network suppliers. In the event that you see a supplier that is not on your arrangement’s rundown – other than in a crisis – you will need to pay the full cost yourself.

How Does EPO Insurance Work?

A kind of overseen, care medical coverage, EPO stands for exclusive provider organization as mentioned earlier. EPO medical coverage got this name since you need to get your medical services only from medical care suppliers the EPO contracts with, or else the EPO would not pay for the care. As is the situation with other healthcare plans that expect you to remain inside their supplier organizations, EPOs will pay for out-of-network care in circumstances involving a crisis.

Like their cousins, PPOs and HMOs, EPO wellbeing plans have cost control rules about how you get your medical care. On the off chance that you do not keep your EPO’s guidelines when you get medical care administrations, it would not pay for the consideration.

An EPO health plan’s guidelines revolve around two essential cost control strategies:

  • For administrations to be covered, you need to get clinical administrations from specialists and medical clinics with whom the EPO has arranged limits, despite the fact that there is an exemption for emergency care.
  • Medical services administrations are restricted to things that are therapeutically fundamental or that make your medical care costs lower over the long haul, similar to preventive care.

It is likewise imperative to know how EPO protection functions. How does EPO health insurance work? What do you have to think about utilizing your EPO medical coverage? Make a point to read your medical coverage strategy cautiously. Remaining in-network and getting pre-approvals when required could spare you a ton of cash. How about we take a gander at the main ideas to comprehend. The following are some important points to consider in the light of how an EPO health insurance works.

You Must Use In-Network Providers

Each EPO has a rundown of medical services suppliers called a provider network. This organization offers each possible sort of medical care administration including specialists, doctors, drug stores, emergency clinics, labs, x-ray facilities, home oxygen, speech therapists and many others.

In an EPO insurance plan, you can just get medical care administrations from in-network suppliers. On the off chance that you get care out-of-network, the EPO would not pay for it; you will be stuck taking care of the whole tab yourself. Coincidentally escaping network care can be a pricey slip up when you have an EPO.

At the end of the day, it is your duty to know which suppliers are in-network with your EPO. For instance, you can’t expect that in light of the fact that a lab is a few doors down from your EPO specialist’s office, it is in-network with your EPO. You need to check. Moreover, do not accept that the imaging office that did your mammogram a year ago is still in-network with your EPO this year. Provider networks keep on changing. In the event that you make that presumption and you are not correct, you will need to take care of the whole mammogram tab yourself.

However, there are three exceptions to the in-network requirement:

  • In the event that the EPO does not have an in-network supplier for the specialty service you need. If this happens to you, pre-arrange the out-of-network specialty service with the EPO. Keep your EPO up to date with what you are doing.
  • In case you are in a mind boggling course of specialty treatment when you become a member of an EPO, and your specialist is not part of the EPO. Your EPO will choose whether or not you may complete the course of treatment with your present doctor dependent upon the situation.
  • For genuine crises, for example in case you are having a stroke, cardiovascular failure, or another genuine crisis you should go to the closest emergency center whether it is in-network with your EPO. Under the details of the Affordable Care Act, healthcare insurance plans are needed to take care of the expense of emergency care received at the closest out-of-network office like it was in-network care. On the off chance that you should be admitted to the clinic from the ER, nonetheless, your EPO may ask the out-of-network ER to move you to an in-network emergency room for affirmation. What’s more, is that it is critical to comprehend that regardless of whether your insurance plan covers the out-of-network crisis care as though it were in-network, they are still simply going to pay the sum that they consider sensible and standard. However, the out-of-network emergency center and doctors do not have an agreement with your guarantor, which implies they are not needed to acknowledge the safety net provider’s payment as payment in full. They can in any case send a balance bill, except if state rules disallow it. The greater part of U.S. states have guidelines set up to shield patients from adjusting charging in crisis situations, but on the other hand comprehend that state medical coverage laws do not have any significant bearing to self-guaranteed wellbeing plans, which cover most of individuals who have business supported medical coverage.

You Do Not Have to Have a Primary Care Physician

Your EPO wellbeing plan by and large would not expect you to have a primary care physician (PCP), despite the fact that getting a PCP is a smart idea. Yet, the policies for essential consideration (and references, as examined underneath) under EPOs, HMOs, PPOs, and POS plans have developed somewhat over the long haul, and will in general be fairly liquid. Here’s an illustration of an EPO plan, offered in Colorado by Cigna, that expects individuals to have a PCP. So the main genuine policy is that you have to give close consideration to the particular subtleties for your own arrangement. The facts demonstrate that most EPOs do not expect you to have a PCP. However, do not accept that yours does not!

You Do Not Need to Have a Referral to See a Specialist

Most EPOs would not expect you to get a reference from an essential consideration specialist prior to seeing a specialist. This makes it simpler to see an expert since you are settling on the choice yourself, however you should be exceptionally cautious that you are seeing just authorities that are in-network with your EPO. A bit of leeway of having a PCP is that they are regularly acquainted with the pros in your locale, and most experts include extraordinary interests inside their specialty, for instance, some broad oncologists may have a unique interest in bosom disease while another may have an exceptional interest in lung cancer.

What’s more, is that much the same as the “rule” about EPOs not expecting you to have a PCP, references can be an ill defined situation as well. The Cigna EPO in Colorado that requires PCPs likewise requires references to see an authority. So once more, interestingly, you are comfortable with the principles that apply to your particular arrangement, or to any arrangement that you are thinking about as another option. Try not to expect anything dependent on whether the arrangement is an EPO, PPO, POS, or HMO!

Expensive Services Require Pre-Authorization

Your EPO will probably expect you to get consent for certain administrations, particularly those which are generally expensive. In the event that a specific help requires pre-approval (earlier approval) and you do not get it, your EPO can decline to pay. The administrations which require approval are elective and not crisis benefits, so a little time postpone would not be perilous.

Pre-approval enables your EPO to minimize expenses by ensuring you truly need the administrations you get. In plans like HMOs that expect you to have an essential consideration doctor, your PCP is answerable for ensuring you truly need the administrations you get. Since your EPO likely does not expect you to have a PCP, it utilizes pre-approval as an instrument to arrive at a similar objective: the EPO just pays for things that are really therapeutically important.

EPO plans vary with respect to what sorts of administrations must be pre-approved. Most require pre-approval for things like MRI and CT filters, costly professionally prescribed medications, medical procedures, hospitalizations, and clinical hardware like home oxygen. Your EPO’s Summary of Benefits and Coverage should reveal to you more about the pre-approval necessity, yet you ought to expect that any costly help should be pre-approved.

In spite of the fact that your primary care physician may elect to get pre-approval for you, after all, it is your obligation to ensure you get help pre-approved before you get the medical services. On the off chance that you do not, your EPO has the option to decline to pay for the consideration, regardless of whether the consideration was therapeutically essential and you got it from an in-network supplier.

Pre-approval requires some serious energy. Periodically, you will have the approval before you even leave the specialist’s office. Normally, it takes a couple of days. In awful cases, or if there is an issue with the approval, it can even take weeks. Look at our tips on the most proficient method to get an earlier approval demand endorsed.

You Do Not Have to File Claims

You do not need to get yourself in the complications of bills and claim forms when you have EPO medical coverage since the entirety of your consideration is given in-network. Your in-network medical services supplier charges your EPO wellbeing plan straightforwardly for the consideration you get. You will simply be liable for paying your deductible, copayment, and coinsurance.

Cost-Sharing Requirements Are Generally Lower As Compared To A PPO

Cost-sharing is a training where both you and your insurance agency pay for a part of administrations. Your segment of the cost-sharing can incorporate deductibles, copayments, and additionally coinsurance. There are no firm guidelines with regards to cost-partaking in the different kinds of wellbeing plans. Some EPOs have significant expense sharing, while others have minimal effort sharing. In any case, by and large, EPOs will in general have lower cost-sharing than PPOs. You can consider that a compromise for the way that as far as possible you are just utilizing in-network clinical suppliers, while PPOs will cover a bit of your expenses regardless of whether you see out-of-network suppliers. In view of its typically lower cost-sharing and low expenses, an EPO is regularly one of the most practical medical coverage decisions.

EPO vs PPO: Which Is Better?

A PPO, or Preferred Provider Organization, is a sort of wellbeing plan that offers a bigger network so you have more specialists and clinics to look over. Your cash based expenses are generally higher with a PPO than with a HMO or EPO plan. In case you are willing to pay a higher month to month charge to get more decision and adaptability in picking your doctor and medical care alternatives, you might want to pick a PPO healthcare plan.

A PPO plan gives you more adaptability than an EPO by permitting you to go to out-of-network suppliers. Then again, an EPO will regularly have lower month to month expenses than a PPO. In any case, in case you are thinking about an EPO, you should check endorsed in-network suppliers in your general vicinity before you choose.

There might be an absence of suitable EPO suppliers close to you, contingent upon where you live. For this situation, your choice would be a lot simpler. However, on the off chance that you can deal with an expanded rigidity in your medical care suppliers, an EPO may eventually prove to be more significant for you or your family.

EPO vs HMO: Which Is Better?

A HMO, or Health Maintenance Organization, is a sort of wellbeing plan that offers a neighborhood organization of specialists and medical clinics for you to browse. It as a rule has lower month to month charges than a PPO or an EPO wellbeing plan. A HMO might be ideal for you in case you are open to picking a primary care physician (PCP) to arrange your medical care and are happy to pay a higher deductible to get a lower month to month medical coverage charge.

Despite the fact that you should pick an essential consideration doctor with most EPOs, you need not bother with a reference to approach a pro—in contrast to a HMO. An EPO’s organization can likewise be more broad than a HMO organization. Except if it is a crisis circumstance, HMOs and EPOs by and large expect you to pay all expenses for any out-of-network care.

The individuals who are young, healthy, and do not really require clinical consideration in the coming year regularly incline toward HMO plans with a low superior (the sum you pay every month) and a high deductible (the sum you need to pay before protection helps cover the rest). This sets aside cash except if you have a physical issue or disease, which is fine for low-risk sorts, however it is not best for everybody.

Do EPO Plans Require Referrals?

An EPO (or “exclusive provider network”) is somewhat similar to a cross breed of a HMO and a PPO. EPOs by and large offer somewhat more adaptability than a HMO and are commonly less expensive than a PPO. Similar to a PPO, with an EPO as well, you do not need to bother with referrals to get care from a specialist. In any case, you will be answerable for paying using cash on hand in the event that you look for care from a specialist outside your arrangement’s organization. The same is the case for an HMO. An EPO is a decent choice on the off chance that you need to see authorities without a PCP reference inside your organization.


EPOs share a few qualities that are similar to HMOs and a few characteristics that are similar to PPOs. Thus, you should seriously mull over an EPO to be a cross between a HMO and a PPO: Like a HMO, you need to remain inside the arrangement’s organization. Yet, similar to a PPO, you are normally not needed to get a reference from your superior consideration specialist to see an authority. Numerous individuals like the simplicity of having the option to plan a meeting with a pro without speaking with a primary care physician. Simultaneously, this can now and then be a test in that you are restricted to specific specialties inside your organization. Having an EPO additionally expects you to effectively engage in arranging costly administrations or techniques, and leaves you basically liable for finishing any earlier approvals required. In general, the mix of its low premiums and minimal cost-sharing make EPOs a decent decision for some individuals.

John Otero

John Otero

John Otero is an industry practitioner with more than 15 years of experience in the insurance industry. He has held various senior management roles both in the insurance companies and insurance brokers during this span of time. He began his insurance career in 2004 as an office assistant at an agency in her hometown of Duluth, MN. He got licensed as a producer while working at that agency and progressed to serve as an office manager. Working in the agency is how he fell in love with the industry. He saw firsthand the good that insurance consumers experienced by having the proper protection. John has diverse experience in corporate & consumer insurance services, across a range of vocations. His specialties include Major Corporate risk management and insurance programs, and Financial Lines He has been instrumental in making his firm as one of the leading organizations in the country in generating sustainable rapid growth of the company while maintaining service excellence to clients.

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