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.