What Is EPO Health Insurance?
Exclusive provider organizations, or EPOs, provide a health insurance option that falls in between HMOs and PPOs in terms of price and access to health care services. It is lesser known than the other two options, but it also may be less expensive for those who are not turned off by some of the restrictions. It is considered a subset of preferred provider organizations, but it does not include reduced fees for out-of-network care.
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PPO vs. HMO
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A preferred provider organization, the root of an EPO, offers access to a network of physicians that a patient can contact for medical services. Unlike with a health maintenance organization, a person with PPO coverage does not need to choose a primary care provider, or a doctor who will serve as the first point of contact. Referrals are generally not necessary in PPOs.
EPO Basics
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An EPO policy may be more cost-effective in certain cases than a PPO plan because a customer is essentially only paying premiums in exchange for coverage by in-network physicians and medical services. They are entitled to receive care from any provider that the insurance company has named, but receive no cost defrayal for services with other offices or hospitals.
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What Isn't Covered
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While a PPO requires a health insurance company to pay for some medical tests and other hospital costs that a patient receives, regardless of network affiliation, an EPO does not. A patient will need to pay for any expenses incurred that were not approved by an in-network doctor and performed at an affiliate institution. Although some PPO plans require patients to pay upfront for out-of-network care, they may also reimburse patients later.
Benefits
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If a patient rarely travels, and is happy with the number of providers offered by an insurance company's EPO plan, then the lower rates combined with the variety of providers they can use may be an advantage. While many out-of-network procedures are not covered by EPO policies, urgent care and emergency room visits are often not included within these restrictions.
Concerns
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A patient who is on an EPO plan may wish to check with doctors about where testing and procedures are being made to limit potential out-of-pocket costs. Some coverage options are also available for those who may want the flexibility of choosing a provider and also have expanded access to other health care facilities, but the costs for out-of-network care may be higher than in both HMO and PPO plans offered by the same company.
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