Frequently Asked Questions • EPO
What is an EPO and how does it different from a HMO?
An EPO (Exclusive Provider Organization) offers two coverage choices or tiers. The first or in-network tier typically provides HMO-like benefits. The second or non-network tier allows participants to obtain care from non-network providers at a greatly reduced benefit level. Benefit reductions may exclude some services from the plan if obtained from a non-network provider. Non-network benefit payments are often limited to the UCR levels established by the insurance carrier.
EPOs differ from HMOs by allowing participants a non-network choice. Most HMOs do not provide coverage for non-emergency services obtained outside their network of physicians and facilities.
What does UCR mean and how does it affect my plan?
If your medical plan includes a non-network option, then UCR limitations are more than likely built in. Regardless of whether your plan is a EPO, POS, PPO or Indemnity, if you obtain services from a non-network provider you will encounter UCR.
UCR refers to Usual, Customary and Reasonable payment limitations imposed by insurance carriers on non-network service charges. UCRs are typically expressed as a percentage. UCRs govern and limit the fee an insurance carrier is willing to honor for services rendered and, as a percentage, reflect the number of providers in a given locale that are charging at or below the established UCR.
What is managed care and how does it impact my medical plan?
One thing most medical plans have in common is "Managed Care".
This includes not only HMOs, but most EPO, POS, PPO and Indemnity
plans too. The term managed care refers to cost containment
features imposed by
insurance carriers, by a medical group, or by a State or
Federal legislative body. Most plan participants encounter
managed care in the form of:
pre-authorization requirements imposed on surgical and other services;
limits on the number of visits available for certain services such as physical therapy, out-patient counseling and chiropractic;
limits on the dollar amounts an insurance carrier will pay for certain services;
penalties for the inappropriate use of an emergency room and other emergency service;
the use of Primary Care Physicians (PCP)/Gatekeepers; and/or
capitation.
Managed care features are specific to a plan and insurance carrier so you may encounter other forms of managed care. The impact of managed care on you will be specific to your plan and personal circumstances.
What is capitation?
When you choose a PCP, you are also choosing a medical group. Capitation is a cost containment feature that provides financial compensation to the medical group with whom your PCP is affiliated. Under a typical capitation arrangement, a medical group receives a monthly payment from an insurance carrier for every patient registered with an affiliated PCP. These payments are placed in a pool of funds from which your PCP receives payment for the services rendered to you. Your PCP is compensated by their medical group, not the insurance carrier. Typically, the medical group is empowered with the responsibility for approving and authorizing the care you receive.
How do I find out if my doctor is in the EPO network?
There are several ways to determine if your doctor is in
your health plan’s network. The best way is to consult the insurance carrier’s online provider directory. Provider directories can be found at most insurance carrier’s home website addresses. The provider directory found there is the most current reliable information. Website links to many insurance carriers can be found in the links section of this website. You may also contact your doctor’s office or your insurance carrier’s
Member Services department.