Understanding EPOs for Open Enrollment 2017 and Beyond

EPOs (or “Exclusive Provider Organization” plans) are plans where you can ONLY use doctors and hospitals within the EPO network, but cannot go outside the network for care. With an EPO there are no out-of-network benefits and no out-of-network maximums except in emergency situations. See an example of an EPO plan here. As you can see from the example, in an exclusive provider network only care at exclusive in-network providers is covered except “If you need immediate medical attention” or “If your child needs dental or eye care.”

Why Care About EPOs?

Exclusive Provider Organization plans are important to understand because some insurance companies are switching to EPOs in 2017. This includes BCBS plans in Washington State and other regions.

An EPO will generally keep your costs down when shopping in-network but can mean very high uncovered costs if you end up out-of-network.

Due to the way the essential health benefits work under the ACA, some EPOs will have to provide emergency out-of-network care in an emergency, but that caveat aside, all care will need to be done in-network. This means, an EPO is like a very stringent version of an HMO and isn’t nearly as flexible as a PPO.

No type is inherently better or worse, but some will likely be a better choice than others for specific families.

When shopping for a health plan, make sure you understand whether or not it is an HMO, PPO, or EPO. Learn more about HMOs and PPOs here. They are more common and we have a whole page dedicated to them.

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Rita on

My Mom was out of network when she fell and broke her hip went thru the emergency room apron arriving Hospital staff helped to get her to the emergency room she passed out eyes rolling back immediately several hospital staff came running to help get my mom inside she came to inside didn’t realize what happened hospital staff immediately started working on her and admitted her into the hospital. She passed out due to the pain, due to the warfarin they couldn’t due surgery for almost 3 days later blood was to thin my mom is 24/7 oxygen, doesn’t have the best memory, now to me that’s was an emergency, insurance company is not paying a lot but refusing payment to many due to out of network the medical bills are pilling have talked with them many times regarding this matter can not get cooperation they never even told me what out of network meant I just found out today what it actually means now how is my mom going to contact anybody under the circumstances to find out if it’s in network or not? How Do I resolve this problem with the insurance co. Can they refuse payment and put it on my mom? Her only income is social security! To top it off she had to go back to the ER AND WAS ADMITTED DUE to congestive heart failure by ambulance this time less then 48 hours from discharge now it’s a double WAMMY..