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Exclusive Provider Organization Plans (EPO Plans)

An EPO is a type of managed care system. The EPO network is made up of care providers which network members must choose from, although exceptions may be made for emergency situations.. Most EPOs require policyholders to choose a primary care physician who will handle most medical issues, and will issue referrals for specialists. EPOs are generally focused on preventative care, and encourages plan subscribers to take steps to stay healthy at all times. EPO carriers are able to negotiate lower rates with health care providers than other types of plans, because EPO members are restricted to in-network doctors only.

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How does an Exclusive Provider Organization (EPO) work?

If you have an EPO plan and need to see a doctor, you will visit your primary care physician (which you will have chosen from your carrier's network of doctors). You will need present your insurance card and pay a small copayment (usually ranging from $10-$30). Claims will be filed on your behalf, so you don't have to worry about extra paperwork. EPOs also charge monthly premiums and deductibles.

How does an EPO compare to an HMO, PPO, and POS plan?

EPOs are similar to HMOs, in that both types of plans require policyholders to see in-network doctors, and do not reimburse policyholders if they visit non-network providers. The differences are that EPO rates are negotiated based on services, while HMOs are determined by on a capitated, or per-person basis; EPO providers are only paid for services provided (HMOs receive monthly payments from carriers); and the premiums for EPOs are generally cheaper than HMOs. EPOs are structurally similar to PPOs, but EPO members cannot file claims for non-network office visits, which PPO and POS plans allow.

Exclusive Provider Organization (EPO) Benefits and Disadvantages

EPOs are beneficial because of their low cost - health insurance carriers can negotiate low premiums and copayments with their providers because they can guarantee that policyholders will visit network doctors only. EPO networks are also better suited for rural areas, which larger HMO networks have trouble covering. EPOs also help their members resolve their conflicts with care providers.

The main disadvantage of an EPO is that it is quite restrictive. The network of doctors tends to be smaller than in HMOs, and it is nearly impossible to see an out-of-network provider without having to pay all of the medical fees out of your own pocket.

Is an EPO Plan right for me?

If you want a fairly low-cost health plan, consider buying EPO insurance. EPOs are especially well-suited for people who are in good health and have little need to see specialists that may be outside of the EPO network.

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