What are Exclusive Provider Organisation Plans

The Exclusive Provider Organisation (EPO) insurance plan is a pocket-friendly insurance plan with affordable monthly premiums. EPO plan definition equates to a managed care health insurance plan where only the insurer’s network provides you with medical care. An EPO insurance plan does not ask for any referral to check in with a specialist. Any treatment or medical expenses incurred outside the network are not covered under this plan, except for emergencies.

 

An extensive network of doctors, hospitals, and other medical care providers are included under the EPO health plan. EPO insurance policies ask you to choose a Primary Care Physician or PCP, who is a doctor that will provide you preventive care and treatment for minor or chronic illnesses. One of the attractive features of this plan includes the option of not wanting a PCP referral to see a specialist. 

How do EPO Plans Work

Insurers form a network for EPO medical insurance by associating with healthcare providers. Through hospitals, pharmacies, labs, specialists, and various other healthcare providers, these plans offer a comprehensive range of healthcare services.  Whenever you need any kind of health care service, you should check in with the provider in the network list. If not, you may have to bear the entire medical expenses by yourself.

 

However, there are three exceptions under the EPO health plan which allow you to take out-of-network services without having to bear the expenses. They are:

 

  1. In case of an emergency like a stroke or cardiac arrest, you can check in to the nearest emergency room. The EPO plan will cover the cost of emergency care even if the hospital is not in the network. 

  2. You can arrange for an out-of-network specialist with the insurer after prior intimation, if your EPO plan does not have a specialist providing a particular healthcare facility.

  3. If you purchased your EPO insurance plan while undergoing a complex treatment in out-of-network care, the plan will cover the treatment cost with the current doctor on a case-by-case basis.

Key Features of EPO Plans

Some of the features of EPO plans are mentioned below.

 

  • Insurance plan with affordable monthly premiums.

  • No out-of-network medical insurance coverage.

  • The policyholder must choose a primary healthcare provider.

  • A visit to an out-of-network healthcare provider needs pre-authorisation.

  • No referral from PCP is needed for specialist visits.

Limitations of an EPO Plan

There are certain limitations to an EPO insurance plan, like:

 

  • Although the EPO insurance premiums are low, coinsurance and deductible are applicable in the plan. 

  • EPO insurance plans don’t cover the healthcare expenses incurred outside the EPO network.

Costing of an EPO Plan

The cost of an EPO plan depends on several factors like:

 

  • The terms and conditions of the insurance plan

  • The place where the policyholder lives

  • Deductible of the plan chosen

  • Coinsurance of the EPO plan

Things to Know about EPO Plans before Investing in them

You have to keep a few things in mind before investing in EPO medical insurance. Let us take a look at them here.

 

  1. It is mandatory to pay premiums on time for the medical insurance maintenance.

  2. Until the EPO plan starts covering the costs, a specified amount should be paid as a deductible.

  3. Once the payment of deductibles are complete, you have to pay copayment or coinsurance.

  4. After that, you have to pay a fixed amount as copays for the covered services.

  5. Also, the maximum cost comes out of your pocket before your EPO starts covering all your costs.

Reasons to Buy an EPO Plan

Here are some reasons why one should buy an EPO insurance plan.

 

  1. The EPO plan benefits include direct access to in-network specialists.

  2. EPO plans are helpful in case of medical emergencies since the policyholder can receive medical care and assistance from both in-network and out-of-network healthcare providers.

  3. EPO insurance plans have lower interest rates compared to other plans like these.

If you don’t have a problem with a limited provider network and prefer the benefits of low insurance premiums, EPO plans are a great choice to make. Since it covers the cost of routine healthcare under network providers and doesn’t mandate a referral from PCP to consult a specialist, EPO medical insurance is reliable. Please note that these insurance policies are available in countries like the United States and not in India. 

 

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FAQs

  • ✔️What is an EPO plan?

    Exclusive Provider Organisation (EPO) insurance plan is a pocket-friendly insurance plan with affordable monthly premiums. EPO plan definition equates to a managed care health insurance plan where only the insurer’s network provides you with medical care.

  • ✔️How costly are EPO plans?

    EPO plans have affordable premiums. The cost of an EPO plan depends on several factors like:

    • The terms and conditions of the insurance plan

    • The place where the policyholder lives

    • Deductible of the plan chosen

    • Coinsurance of the EPO plan

  • ✔️Do I have to file claims for an EPO plan?

    No, you don’t have to file claims for an EPO Plan. The insurer associates with an extensive network of doctors, hospitals, and other medical care providers to formulate a network of hospitals from which you can access cashless facilities to avail of medical services. 

  • ✔️Is the EPO insurance plan available in India?

    No, EPO insurance plans are currently not available in India. It is available in countries like the United States. 

  • ✔️Are there any exceptions under the EPO health plan which allows you to take out-of-network healthcare services?

    Yes, there are three of them. They are:

    • In case of an emergency like a stroke or cardiac arrest, you can check in to the nearest emergency room. The EPO plan will cover the cost of emergency care even if the hospital is not in the network. 

    • You can arrange for an out-of-network specialist with the insurer after prior intimation if your EPO plan does not have a specialist providing a particular healthcare facility.

    • If you purchased your EPO insurance plan while undergoing a complex treatment in out-of-network care, the plan will cover the treatment cost with the current doctor on a case-by-case basis.