What are the EPO health insurance schemes? – Forbes Advisor


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A comprehensive health insurance plan is beneficial regardless of your general health and medical history. Health insurance helps pay for routine care, like an annual exam, as well as emergency procedures, hospitalization, prescription drugs, and other forms of care that can be expensive when paid for from their pocket.

Choosing the right health insurance plan for your needs is often easier said than done. There are several types of health insurance available, including an Exclusive Provider Organization (EPO) plan.

What is an EPO?

An EPO plan is a type of health insurance that helps pay for medical care, but only if it comes from doctors and hospitals in the plan’s network.

When you receive in-network medical treatment, the insurance company pays part of the bill and you pay what’s left based on your deductible, coinsurance and maximum out-of-pocket.

A deductible is the amount you pay for covered services before your health insurance plan begins to help pay for your care. Coinsurance is the percentage of covered health insurance costs you pay after paying your deductible amount. Your maximum outgoing is the maximum you pay for your health care for the year.

An EPO does not pay for out-of-network care. If you receive out-of-network services, you are responsible for covering the entire cost, except for emergency medical care.

An EPO is the second most common type of health plan in the Affordable Care Act (ACA) market. EPO plans make up 31% of all plans selected in the ACA are EPOs, second only to health maintenance organization (HMO) plans, according to a Forbes Advisor analysis of ACA plans.

How does an EPO health plan work?

An EPO health plan allows you to get medical treatment from providers and facilities that have contracted with the health insurance company. These health care providers and facilities are considered “in-network”. The insurance company agrees to pay these doctors a certain amount for medical treatment and services.

When you get in-network care, the health insurance company covers most of the cost. You pay the remaining balance in the form of deductible, copayments and coinsurance (depending on the plan). A co-pay is a fixed amount you pay for doctor visits and prescriptions after you pay your deductible.

One of the benefits of EPO insurance is that you don’t need a referral to see specialists. However, you must choose a specialist from the EPO network for the insurer to pay for the visit.

Another thing to know about EPO health insurance is that pre-authorization may be required before the insurance plan will cover certain medical procedures and treatments. From the insurance company’s point of view, a pre-authorization limits unnecessary care.

How much does an EPO health insurance plan cost?

An EPO plan costs an average of $436 per month for a 30-year-old male. See more average below based on age, individuals, couples and families.

EPO plans cost a little more than an HMO plan and a lot less than a Preferred Provider Organization (PPO).

Cost of EPO vs HMO vs PPO

The cost of health insurance is based on a few factors, including your age, smoking status, plan level, and dependents. In general, seniors and smokers pay the highest rates for an ACA market plan, as well as people with multiple dependents.

The cost of EPO insurance also depends on how you purchase the policy. For example, if your employer offers EPO health insurance, the cost is lower because your employer subsidizes part of the health insurance premium.

On the other hand, buying a private EPO plan from the health insurance market will be more expensive because you pay 100% of the premium. But government grants based on your income and family size can help lower that cost, if you qualify.

The only way to find out how much you’ll pay for an EPO plan is to get quotes from insurance companies or go to the market at Healthcare.gov.

Benefits of the EPO

  • More affordable monthly premiums: The cost of an EPO health insurance plan is usually cheaper than a PPO plan.
  • References not required: You don’t need a medical referral to see a specialist, such as a cardiologist or physiotherapist.

Disadvantages of EPO

  • Out-of-network care is not covered: Out-of-network care is not covered by EPO plans except for emergency care. If you want to see an out-of-network doctor, you must pay the full medical bill.
  • May have high direct costs: Some EPO plans have high out-of-pocket expenses, such as a deductible and coinsurance, which can increase the cost of coverage. However, it depends on the specific plan and level you select.

EPO versus HMO

Both an HMO plan and an EPO require you to receive medical treatment from an in-network provider. The insurance company will not cover any medical treatment received out of network with either plan.

If you have an HMO, you need to work with a primary care provider and you need a referral to see a specialist. An EPO allows you to manage your own care and referrals are not required.

In terms of cost, EPO plans are generally more expensive than HMOs, given that they offer a bit more flexibility. HMO plans can be a good option if you’re looking for the cheapest plan and don’t mind working with a doctor to coordinate your care.

Differences between EPO and HMO

EPO versus PPO

A PPO plan offers the most flexibility to see any doctor you choose, whether in-network or out-of-network.

Your insurance company pays the highest amount for in-network care and a lower percentage for out-of-network care, so PPO members pay more for out-of-network care. In contrast, an EPO plan does not pay for any portion of out-of-network care (except in an emergency).

Like an EPO plan, PPO plans don’t require you to work with a primary care provider or get a referral to see specialists. But due to the increased flexibility and higher coverage levels, PPO plans are usually more expensive than EPO plans.

Differences between EPO and PPO


Point-of-service (POS) health plans, which are not common, are a hybrid between a PPO and HMO plan.

With a POS plan, you must work with a primary care provider who oversees your medical care, and in most cases referrals are needed to see a specialist (like an HMO). But point-of-sale plans allow you to get treatment from an out-of-network provider and cover some of the cost (like a PPO).

Compared to an EPO plan, POS plans often have smaller networks with fewer doctors and facilities. Therefore, the cost of an EPO plan is often slightly higher than a POS plan, but this depends on factors such as plan level and out-of-pocket fees. Outlets are only a small part of health plans, so you might have a hard time finding one.

Differences between EPO and POS

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Who should get EPO health insurance?

An EPO health insurance plan can be a good option if you don’t want to bother getting referrals and want to manage your own care without the help of a primary care provider. It’s also a good choice if you’re looking for a plan with some flexibility but don’t want to pay the highest premium for a PPO plan.

Keep in mind that an EPO plan does not provide coverage for out-of-network care. If you want the freedom to choose the doctor or hospital of your choice or if you currently work with providers that are not part of the EPO network, an EPO plan may not meet health insurance needs. of your family.

Frequently asked questions about EPO health insurance

Does an EPO cover out-of-network care?

No, an EPO health plan does not cover out-of-network care unless you are receiving urgent or emergency medical treatment. If you receive treatment from a doctor or facility that is not part of the EPO network, you are responsible for paying the bill without the help of health insurance. Unlike a PPO plan, EPO plans do not have cost sharing for out-of-network care.

Do you need a primary care doctor if you have EPO?

If you have an EPO insurance plan, you do not need to work with a primary care physician. You have the ability to manage your own care and choose your own doctors. Since primary care visits aren’t necessary, you can also speed up your treatment by making an appointment with a specialist right away.

Do EPOs need a referral to see a specialist?

No, you do not need a referral to see a specialist if you have an EPO insurance plan. You can make appointments and self-select specialists without having to see your primary care provider first. However, you need to choose networking specialists. Otherwise, the visit will not be covered.


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