Benefits of EPO Health Insurance

When it comes to group health insurance plans, most people have heard of HMOs and PPOs. But how about Exclusive Provider Organization plans (EPOs)? While these plans are not as well known as HMOs and PPOs, they might be a good option for your business. What they lack in flexibility, they can sometimes make up for in savings, so there are benefits to choosing an EPO plan for your employees. If this type of plan is unfamiliar to you, take a look at how these plans work and see if an EPO might meet your needs.

How EPOs Works

EPOs are managed care plans that combine some of the aspects of HMOs and PPOs. Like HMOs, EPOs offer a full network of doctors and hospitals to choose from, but with an EPO your employees must get their health care exclusively from health care providers within the network. If they seek care out of the network, the plan will not cover any of those expenses and your employees will have to pay out of pocket. 

a bunch of people in red in different locations connected by lines, with people in white around not connected.
EPO plans allow employees to go to any doctor within the network, but if they go outside, then they will have to pay out-of-pocket.

Exceptions to EPOs’ in-network rule are only allowed when:

  • The plan does not include an in-network provider for the service needed. 
  • Your employee is sent to the nearest emergency room that is not in-network during an emergency such as a heart attack, stroke, or accident.
  • Your employee is in the middle of specialty treatment and the specialist is not part of the network. 

While EPOs are less flexible than HMOs in some ways, they do allow more flexibility than HMOs when it comes to referrals. With an EPO, as with PPOs, your employees will not need to get a referral from their primary care physician. So EPOs have that one big selling point of PPOs, while offering more affordable premiums than PPOs.

When Pre-Authorization Is Needed

One thing that is different about EPOs is that healthcare services are limited to medically necessary care, or care that helps lower long-term healthcare care costs, like preventive care. This means that EPO plans require permission for some specific services, especially more expensive ones. If employees need an expensive medical service, the plan will require pre-authorization for that service, which can take a few days or possibly weeks. If the service is not authorized, the plan will not pay for the service. It is the policyholder’s responsibility to request prior approval before receiving services including:

  • MRI and CT scans
  • Expensive prescription drugs
  • Surgeries
  • Hospitalizations
  • Medical equipment

Advantages To Offering an EPO Planillustration of hands in a suit holding a bag with a money sign on it.

There are some advantages to offering an EPO plan to your employees, including:

  • Savings- EPO plans focus on the right amount of care needed which can help keep expenses down for you, and can lower out-of-pocket costs for employees.
  • Care management- Because EPOs have a set network of providers, doctors will have total connectivity to their patients’ records instantly, which will allow for better care and more cost-effective medical outcomes. 
  • No PCP or referrals needed- Employees will not need to choose a primary care physician and will not need to get referrals to see a specialist as long as they are in-network.

Need Help Finding A Plan?

EPO plans have many money saving benefits for both you and your employees. They combine certain aspects of PPO and HMO plans, but have lower monthly premiums than other plan types. If you want more information on EPO plans and whether one might be a good fit for your business and employees, come to EZ. EZ.Insure will compare all available plans in your area and determine which plan suits your needs and budget. We will provide you with free quotes as well as any information you need to better understand how these plans work. To get started, simply enter your zip code in the bar above, or to speak with one of our licensed agents, call 888-998-2027.

About The Author: Cassandra Love

With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.
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