Choosing a health insurance plan can feel daunting. Once you’ve decided on the right insurance company, you’ll have to decide what type of plan is the best fit for your needs. While the costs will vary by state, the general guidelines for each plan remain the same. One common type of health plan is known as an “Exclusive Provider Organization Plan” (EPO). Depending on your individual healthcare needs and financial position, an EPO plan might be the right fit for you. If you are currently enrolled in a PPO or HMO, keep reading to make sure you’re getting the most from your policy.
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Understanding EPO insurance
According to Healthcare.gov, an EPO is “a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).” In other words, when you are enrolled in an EPO plan, you can only see doctors inside of your network. Any treatments or services done outside of your network will not be covered by the insurance company. The only time out-of-network coverage is allowed is in emergencies. If you need to go to the emergency room, you’ll be covered. While you might be limited to your network, you can see any specialists you’d like to, without getting a referral first.
In a nutshell, an EPO plan will grant you access to emergency hospital care, specialists without PCP approval, and a committed network of doctors. You might not be able to see a specific doctor that doesn’t have a relationship with your insurance company, but you should have no problem finding an in-network replacement.
EPO plans aren’t for everyone, but depending on your current situation, you might find that you would have been better off with an EPO plan this whole time. If you’d like to know what makes an EPO plan unique, it helps to understand a little bit about the other options out there.
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How is EPO different from PPO and HMO?
Some people might consider an EPO to be almost like a hybrid version of a PPO and HMO. Which of the three is the most favorable depends on the priorities of the insured. What one patient sees as a burden might feel like a layer of security to another.
Some things that you’ll want to consider are:
- An EPO does not require referrals to see a specialist, but it will usually require you to select a primary care physician (PCP).
- An EPO only provides coverage for in-network providers.
- An HMO does not cover out-of-network providers in any capacity.
- An HMO will require you to select a PCP because you need one to get referrals to see a specialist.
- A PPO plan will not require you to select a PCP and will provide partial coverage for out-of-network costs.
- A PPO plan usually has a higher premium because it allows for partial out-of-network coverage.
One of the greatest benefits of an EPO plan is that you won’t need any referrals. If you want to see a specialist, you just need to make sure they’re in your network! This can save you a lot of time and frustration, as some people aren’t able to get the referrals they need. When the process is more complicated, it becomes much more likely for the insured person to go untreated. You might wonder if limiting yourself to in-network providers only sound less beneficial, but if you don’t need to go through a PCP to seek out specialists, it isn’t as restrictive as it may sound.
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Is EPO insurance expensive?
Whether you consider your EPO plan to be expensive will depend on your circumstances. Since EPOs require patients to stay inside their network, insurance companies will have contracts arranged with all the providers. This allows the insurance company to keep premiums lower than other plans, like a PPO, which boasts a high average premium cost in comparison with all other options.
The typical EPO plan will offer a premium that falls somewhere between your average HMO and PPO. When you’re looking at the premium cost of an EPO plan, make sure to take every factor of insurance into consideration. For example, you are going to incur expenses with copayments, deductibles, and coinsurance, so you’ll want to get an idea of the bigger picture before you select a plan.
If you need help paying for your health insurance, consider reaching out to your local state health department. Depending on your situation, you might be eligible for various government assistance and other financial aid programs. Some things they will take into consideration are your income, number of dependents, and taxpayer status.
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Is EPO insurance right for you?
Perhaps the most obvious benefit of an EPO plan is that you are free to visit specialists as you wish. If you’re someone who typically goes beyond your annual check-up, you might want to consider an EPO plan. Getting a referral means you must essentially double your first doctor’s appointment for each medical issue that presents itself. If you want to see a dermatologist, you’ll need to go to your PCP first. That could mean you’re paying almost twice as much in copayments on that first visit. If you need to see a neurologist another time, you’ll have to go see that PCP first, pay that copay again, and the process continues.
Of course, there are times when seeing your primary care doctor before a specialist is necessary. However, there are other times when you know exactly what the issue is, and you just need to gain access to the most qualified person to provide you with treatment. In this type of situation, a referral waiver is exactly what you need to get back to feeling your best.
Another thing to consider is your in-network providers. If your health insurance is sponsored by your employer, you won’t have any control over what doctors are in-network. So, if you already have preferred doctors that you want to continue seeing, you might end up going out of network to see them. In this case, an EPO plan might not be the best fit, as they don’t provide any coverage for out-of-network providers. If you wind up with an insurance company that doesn’t work with your preferred providers, you should have an idea of how you’re going to handle that. If you’re willing to take advantage of the referral-free visits and find an in-network provider, then an EPO can serve you very well. You’ll also end up saving on premium costs, as the plans with out-of-network coverage typically cost more than those that don’t.
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Conclusion
There’s nothing more important than the health of you and your loved ones. Whether your insurance is for your entire family, or just you, take the time to be diligent when weighing your options. What might seem like a minor difference at first could end up having a serious impact on your finances. If you jump to whatever plan seems like it’ll be the cheapest, you might wind up responsible for a lot of out-of-pocket costs you didn’t expect. When you’re ready to enroll in a health plan, the easiest way to begin is by assessing your current situation. Think about what your healthcare needs are right now, and consider what healthcare providers you currently use, if any. Make sure you consider the upfront costs as well as what expenses you might incur down the road.
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