Exclusive Provider Organisation
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Exclusive Provider Organizations (EPO)
What is EPO Insurance?
How Does an EPO Plan Work?
EPOs enter into a contract with a set of physicians, specialists, laboratories, and hospitals to provide medical care to its members. These entities are called in-network providers. A healthcare provider who is not contracted to work under this plan is called an out-of-network provider.
The members get insurance coverage only for medical services provided by in-network providers. But for emergencies, they also get coverage for services from out-of-network providers.
EPO health insurance plans do not require their members to have a designated primary care physician (PCP) for routine medical services. But it is a good practice to have a PCP to manage and coordinate all your healthcare needs.
Apart from premiums, EPO plans have certain out-of-pocket expenses such as copayments, deductibles, and coinsurance.
How Much Does an EPO Plan Cost?
Premium
This is the fixed monthly or annual fee that you must pay to get insurance coverage
Copayments
A copayment is a fixed amount that you pay to receive any service covered by the EPO plan. For example, the copayment to consult a doctor can be AED 100.
Deductibles
A deductible is an amount that the member has to pay before the insurance plan starts to pay for the expenses. If the plan has a deductible of AED 1000, the member has to first pay AED 1000 toward medical expenses. Only the excess (if any) shall be paid by the insurance plan.
Coinsurance
This feature splits the cost of medical treatment between the insurer and the policyholder. If the coinsurance is 25%, the health insurance company will pay 75% of the medical expenses, and the balance of 25% has to be paid by the member or policyholder.
Benefits of an EPO Plan
Lower Costs
EPOs enter into a contract and negotiate the costs of medical services with various healthcare providers. This helps to lower the expenses for members of the EPO plan.
Network
EPOs build a strong network of doctors, specialists, clinics, hospitals, and diagnostic laboratories. This network is much bigger than other managed healthcare plans like HMOs or PPOs.
Flexibility
EPO plans do not mandate their members to have a designated primary care physician (PCP). This provides the flexibility to consult a specialist without a PCP referral.
Point of Service (POS) Plans
POS stands for point of service. Under a point-of-service plan, policyholders can also select healthcare providers who are not part of the network. The POS insurance meaning is that at every point, the members have a choice to stay within the network or access services outside the network.
What is POS Health Insurance?
How Does a POS Plan Work?
A POS insurance plan combines the features of health maintenance organization (HMO) and preferred provider organization (PPO) plans. So a POS plan requires the services of a designated primary care physician (PCP) to make referrals to a specialist if required. This feature is similar to an HMO plan.
Just like a PPO plan, a POS plan gives you the flexibility to choose out-of-network healthcare providers. But the level of benefits essentially depends on whether you choose an in-network or an out-of-network provider. Any service received from out-of-network providers may entail certain additional expenses in the form of copayments, deductibles, and coinsurance.
How Much Does a POS Plan Cost?
A POS health plan is a combination of HMO and PPO plans. So the cost of a POS plan generally lies between these two plans. It costs as much or more than an HMO plan. You may incur higher out-of-pocket expenses if you choose to receive medical care outside the network. But overall, it is more affordable than a PPO plan.
POS Health Insurance Pros and Cons
POS insurance plans have their own set of advantages and limitations. A clear understanding of the same will help you choose the right plan for your needs.
- Budget-Friendly : A POS plan costs less than a PPO plan. It is ideal if you do not have bigger medical expenses.
- Flexibility : Though you pay slightly more for out-of-network service, you can access a large network of healthcare providers in a POS plan.
- Balance : A POS plan is a middle-ground between HMO and PPO plans. You enjoy a higher degree of flexibility and a choice of service providers at a reasonable cost.
POS Health Insurance Pros and Cons
POS insurance plans have their own set of advantages and limitations. A clear understanding of the same will help you choose the right plan for your needs.
- Pricing : Though point-of-service plans are cheaper than PPOs, they cost as much or about 50% more than HMO plans
- Complexity : POS plans are not as standard as HMO or PPO plans. It can be quite confusing to understand the details of this plan. Members do not get a clear idea of the exact costs.
- Paperwork : The paperwork is quite tedious if you select a provider outside the network. It is pretty taxing to file a claim for reimbursement and wait for its processing.
EPO vs POS Insurance Plans
Network Hospitals
An EPO is similar to an HMO plan. It does not cover medical services received outside the plan’s network of healthcare providers. A medical emergency is the only exception to this rule. But you have the flexibility to choose out-of-network providers under a POS plan.
Primary care physician
A POS insurance plan requires the services of a designated primary care physician (PCP) to refer the case to a specialist. But EPO plans have no such mandatory requirements to consult a specialist. This is highly beneficial for members with chronic health conditions.
Frequently Asked Questions about EPO & POS Health Plans
An EPO health insurance plan does not pay for out-of-network services (except in a medical emergency). This helps to manage the costs and ensures that insurance coverage is provided only for essential medical services.
Both EPO and POS plans have their own benefits and disadvantages. An EPO plan only covers in-network services but does not require a PCP referral to consult specialists. A POS plan offers a wider choice of both in-network and out-of-network providers. But here, you cannot meet a specialist without a PCP referral.
A PCP acts as the first point of contact to manage and coordinate all your healthcare needs. This is highly beneficial for people who require the support & guidance of a qualified professional to oversee their medical condition and related requirements. A PCP is also like a family physician who can provide routine medical care.
Disclaimer: The health insurance policy or plan may have limitations, exclusions, and other terms and conditions that may affect coverage. It is important to carefully review the policy wording before making any decision.