An Exclusive Provider Organization (EPO) health insurance plan is one of the "managed care" system offerings in America. It involves a network of medical care providers, which provide healthcare to the subscribers of the health insurer. The subscribers are required to chose a primary care physician from within the network. EPOs are beneficial because of their cost effectiveness, since the insurer can negotiate low premiums and co-payments with their providers based on the guarantee that policyholders will visit network doctors only.
• PPO members can receive reimbursement upon using services from providers other than those designated.
• Reimbursements are at a reduced rate, which may include higher deductibles, copayments, lower reimbursement percentages, or a combination of these disadvantages.
• Some EPOs allow partial reimbursement outside of the network in emergency cases.
• In HMO plans, as with an EPO, choosing out-of-network medical provider, implies the entire payment of the provider's bills.
• EPO rates are negotiated based on services, whereas HMOs are determined per-person basis.
• HMOs receive monthly payments from carriers, while EPO providers are only paid for services provided.
• HMOs are generally more expensive than EPOs.
• An HSA plan is a combination of high-deductible insurance plan and tax-favored savings account.
• As compared to an EPO plan, it has tax benefits and lower monthly premium rates associated with it.
EPOs, though cost effective, are quite restrictive since the network of doctors is usually smaller than in HMOs, and it is nearly impossible to see out-of-network providers without paying the entire medical fees from one's own pocket.
America's Health Insurance Plans (AHIP) co-sponsored a Health
Care Cost-Containment Summit in March 2011 in Washington D.C.
Summit panelists discussed solutions that will enable the nation to build a sustainable, high quality health care system. Read conference summary
View presentation developed for the National Conference of State Legislatures.
View monthly premium costs (family coverage) by state as compiled by the National Conference of State Legislatures (NCSL).
Changes are underway regarding medical diagnosis and reporting. All medical offices and other health industry professionals must implement ICD-10 code sets in October 2013. View fact sheet