EPO is one of the most common types of health insurance plans offered by employers. According to an eHealth survey, EPO plans accounted for 12 percent of all plans selected in 2018. An EPO is a managed care plan in which services are only covered if the patient sees a doctor, specialist or hospital within the plan’s network. However, there are some exceptions to this rule, such as if the patient experiences a medical emergency.
EPO is just one of several common health insurance plans offered by employers. Others include Preferred Provider Organization (PPO), Health Maintenance Organization (HMO) and Point of Service (POS) plans. Before offering any type of plan to employees, it is important to understand how exactly each plan works to ensure that they meet the unique needs of the business and its employees.
What Does EPO Stand For?
EPO stands for Exclusive Provider Organization meaning insureds must get their health care exclusively from health care providers that the EPO contracts with or risk not receiving coverage. Unless it is an emergency, the insurance will not generally pay for expenses incurred from providers outside of the network. In addition, most EPO insurance plans require patients to choose a primary care physician (PCP). Primary care physicians provide preventive care and treat certain minor and chronic health conditions.
Another unique feature of an EPO is that patients do not need a referral from their PCP to see a specialist. This means that patients can contact specialist physicians directly and schedule appointments. Although EPO plans restrict which health care providers a patient can see, patients can usually enjoy lower monthly premiums as providers within the network have contracts in place with the insurance company.
The Affordable Care Act (ACA) prevents health insurance companies from charging higher coinsurance or copayments for out-of-network emergency care. This means that if a patient needs an ambulance or is admitted to the ER, an EPO will generally cover these expenses. However, not all trips to the emergency room are considered true emergencies under an EPO plan. It is important for patients to review the unique terms of the plan to see what constitutes as an emergency.
How Is It Different From Other Plans?
There is currently no law in place that requires employers to provide health care coverage to employees; however, offering health plans can be an excellent way to attract talent and maintain reliable staff. Choosing the right type of health insurance is not always an easy decision. Employers that offer health insurance plans to employees must consider not only the type of plan, but also the age of employees, the cost of the plan and the amount of coverage. Consider how EPO plans compare with other types of employer-sponsored health insurance plans, such as PPO, HMO and POS insurance.
EPO vs. PPO Insurance
A PPO is a type of health insurance plan that covers care provided both inside and outside of a plan’s provider network. However, in exchange for the ability to see any provider they choose, members generally pay a higher percentage of the cost for out-of-network health services. Unlike an EPO, patients under PPO insurance do not need to choose a primary care physician. However, similar to an EPO, patients do not need a referral to see a specialist. PPO insurance members may be responsible for a portion of the bill if they see an in-network provider and an even higher portion of the bill if they see an out-of-network provider.
EPO vs. HMO Insurance
HMOs are one of the most affordable health insurance options on the market. Most HMO plans have low deductibles and premiums, as well as fixed copays for doctor visits. Similar to an EPO, an HMO requires members to choose providers within their network. Members must also choose a primary care physician to see for regular checkups. HMO insurance plans will not pay for care that is received by an out-of-network provider or hospital. What makes HMOs different from EPOs is that these plans require a referral from a PCP to see a specialist.
EPO vs. POS Insurance
POS plans are essentially a hybrid of a PPO and an HMO. Similar to a PPO, members pay less if they visit a doctor or hospital that is in the plan’s network. Access to out-of-network providers is available but at an increased cost. Similar to an HMO, members need to get a referral from their PCP to see a specialist. POS insurance plans are not as common as other plans, such as an EPO; however, this plan does provide members with more flexibility to see whichever providers they would like in exchange for paying a larger portion of the final bill.
How To Acquire An EPO Health Insurance Plan
Today, business owners have a wide range of options when it comes to health insurance. Even smaller businesses that do not have the help of a massive HR department can acquire an EPO insurance plan for their employees. Hiring an insurance broker is an excellent option when shopping for health insurance. An experienced insurance broker can help a business compare health insurance options and provide advice on which plans are best based on cost and similar factors. Brokers act on behalf of their clients and possess extensive knowledge of different types of insurance products and their risks.
Speak To An Experienced Benefits Consultant
Exclusive provider organization plans provide members with a moderate amount of freedom to choose healthcare providers and specialists. Many EPO plans also come with affordable coinsurance or copayments, as well as no claim forms to fill out and no charge for preventive care. EPO insurance is generally less expensive than both PPO and HMO plans which can lead to major cost-savings. It is important to read the fine print of the plan as not all EPO insurance has the same coverage terms. Learn more about EPO insurance plans or speak with an experienced benefits consultant at Business Benefits Group about your options.