Small Business Health Insurance: The EPO Plan Explained
If you’ve been researching health insurance options for your small business, you’ve likely encountered the term “Exclusive Provider Organization” or EPO. This lesser known plan has its advantages, and it’s important to know all of your options before you make a decision. So, we’re breaking it down for you, including how an EPO differs from other health plan types, like a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO).
Here are answers to five frequently asked questions about EPOs.
1. What is an EPO?
An EPO is a health plan that combines the traditional features of an HMO with the flexibility of a PPO. Like an HMO, an EPO offers members access to a network of doctors and hospitals from which to choose. Also, like an HMO, it offers a budget-friendly premium. However, an EPO may limit or not pay for services outside of your EPO plan network (except in case of an emergency).
2. Where can I buy EPO coverage?
Roughly half of California is served by one or more EPO plans. CaliforniaChoice offers multiple EPO options among its carriers. Oscar Health offers 11 EPO plan options in Los Angeles County and Orange County, including two Bronze tier plans, three Silver plans, four Gold plans, and two Platinum plans. Anthem Blue Cross offers two Silver tier EPO plans and one Bronze tier EPO plan through CaliforniaChoice.
3. Does an EPO require me to have a Primary Care Physician, who will refer me to other specialists when I need care?
With an EPO, you typically do have a Primary Care Physician (PCP) who will help you manage your health care. However, not all EPOs require your PCP to make referrals. Some plans, like the Anthem Blue Cross EPO and Oscar Health EPO, allow you to self-refer as long as your specialist is part of your plan’s EPO network.
4. What if I need emergency care and have to go to the hospital?
If you have an unexpected emergency need for medical care, an EPO will generally cover your treatment at least for some part of your stay in the hospital. However, you must get a pre-certification for non-emergency hospital care. Special rules typically apply for maternity stays of less than 48 hours. Ask your broker or review your health plan enrollment materials for details.
5. How do I know if my preferred doctor is part of an EPO’s network?
Insurers in the state that offer EPO health plans have provider lists available on their websites. If you offer CaliforniaChoice to your employees, it’s easy to look up doctors and specialists using the Provider Search tool at calchoice.com. You can search for a doctor by name, gender, city or ZIP Code, distance from home or work, affiliated health plan(s), hospital, or medical group, and language(s) spoken.
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If you want to learn more about EPOs, your employee benefits agent can help.