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What is an EPO?

What is an Exclusive Provider Organization (EPO), and is it right for you?

An EPO is a type of health plan that falls somewhere between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) in terms of cost and flexibility. An EPO plan offers in-network coverage only and does not require referrals for specialty care. EPO members may be required to select a PCP. Also, EPO plans don’t cover out-of-network care unless it’s an emergency.

Some EPO plans are available with Health Savings Accounts (HSA). An HSA can help members save money. The money members put in their HSAs is tax-deductible, and withdrawals are tax-free when used to pay for qualified medical expenses. The HSA account balance rolls over from year to year, and the money in the account belongs to the member. Learn more about HSAs from AmeriHealth.

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Advantages of an EPO

  • In-network coverage
  • No referrals
  • Out-of-network coverage for emergencies
  • Health Savings Account options

How does EPO health insurance work?

EPO plans contract with doctors and hospitals to provide care to the health plan’s members. These providers are called network providers or in-network providers, and they include physicians, specialists, and facilities, like labs, hospitals, and urgent care centers. A provider that does not have a contract with the health plan is called an out-of-network provider.

  • EPO members are only covered for services received from in-network providers. So, it’s important for EPO members to know which providers are in their network.
  • EPO members are covered for emergency care no matter where they are — in or out of network.

While EPO plan members aren’t required to use a primary care physician (PCP) to coordinate their care, a PCP can help them manage their long-term health and save them time and money by helping them understand their options for certain services, including:

  • Retail clinics, urgent care centers, and telemedicine visits (if available)
  • Blood work and other laboratory services
  • Outpatient surgery

Cost, deductibles, and copays

In addition to a monthly premium, EPO members may have out-of-pocket costs when they receive care.

  • Coinsurance — This is the percentage the member pays for some covered services. If the coinsurance is 20 percent, the health insurance company will pay 80 percent of the cost of covered services, and the member will pay the remaining 20 percent. The amount the member pays is typically not based on the full retail price of the service. It is based on a discounted rate negotiated by the insurance company with heath care providers like doctors and hospitals.
  • Copay — A copay is the set amount a member pays for a covered health care service. For example, the copay to see a doctor could be $20, while the copay for an emergency room visit could be $100.
  • Deductible — This is the amount a member pays each year before the health plan starts to share the costs. For example, if the health plan has a $1,000 deductible, the member pays the first $1,000 of the costs for the services received. Once the deductible has been met, the insurance will pay for some or all health care services, depending on the health plan.

Is an EPO the right health insurance plan for you?

Here are some things to consider when deciding if an EPO is right for you:

  • If you want to save money on health care costs, an EPO insurance plan with a health savings account (HSA) may be the best option.
  • If you see the doctor often or would like your primary care physician to coordinate your care with referrals, an HMO plan may be a better option for you.

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