A form of PPO, in which patients must visit a caregiver who is on its panel of providers. If a visit to an outside provider is made, the EPO will offer limited or no coverage for the office or hospital visit.
EPO EPO is an insured product marketed by health insurance companies as a variation of a PPO product, usually with a more limited provider network. In most EPO's, members choose a Primary Care Provider who is responsible for coordinating care, and members must use the EPO limited network to obtain maximum benefits. If a member chooses to go outside the EPO network, the services may not be paid or may be paid only at a lesser benefit level.
A prepaid medical group plan that provides a predetermined medical care benefit package. EPO is the acronym used by a plan that is self insured.
Health insurance plan that provides benefits only if care is provided by a particular group of medical providers with some limited exceptions such as emergency, urgent care and skilled nursing facilities. The Only@Stanford Health Plan is an example of an EPO offered to Stanford University faculty and staff. In order to receive benefits under this plan you must go to Stanford Hospital and Clinics, or Lucile Packard Children's Hospital, Menlo Medical Clinic, or Welch Road Pediatrics for all your medical care. Access to medical providers is limited to those listed above, except for cetrain situations such as urgent care, a life-threatening emergency or care in a skilled nursing facility.
A type of preferred provider organization where individual members use particular preferred providers rather than having a variety of preferred providers to choose from. EPOs are characterized by a primary physician who monitors care and makes referrals to a network of providers.
A managed care organization that designates specific providers who can provide health care services. The term is derived from the phrase preferred provider organization (PPO). However, a PPO generally extends coverage for non-preferred provider services as well as preferred provider services. An EPO provides coverage only from contracted providers. Technically, many HMOs also can be described as EPOs.
A managed care organization that is organized similarly to PPOs in that physicians do not receive capitated payments, but which only allows patients to choose medical care from network providers. If a patient elects to seek care outside of the network, then he or she will not be reimbursed for the cost of the treatment. See Preferred Provider Organizations.
A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure, and operation, but which does not cover out-of-network care.
The provision of a medical service in exchange for a fee. This is now commonly used to describe traditional insurance or indemnity plans where the insured has the freedom to go to any medical provider and the insurance company pays on a usual, customary and reasonable basis.
A medical plan that offers its members a wide range of medical services from a specific group of medical providers.
A group of hospitals, physicians and other providers who provide health care services to covered patients. Patients are covered only within the EPO; if they seek care outside of the network, they must pay for it themselves. See Preferred Provider Organization.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation, but which generally has a lesser number of network providers.
Similar to an HMO, an EPO is an integrated healthcare delivery system in which the members of the EPO must obtain medical services and supplies from network providers in order to receive benefits. Any services rendered by non-network providers are not covered.
Form of managed care in which participants are reimbursed only for care received from affiliated providers.
A health care benefit arrangement that is similar to a health maintenance organization (HMO).
A closed panel of providers that beneficiaries must use to receive covered benefits; some exceptions are usually included for emergency and out-of-area services.
a dental benefit plan that provides benefits only if care is rendered by institutional and professional providers with whom the plan contracts (with some exceptions for emergency and out-of-area services).
A plan that limits coverage of non-emergency care to contracted health care providers. Operates similar to an HMO plan but is usually offered as an insured or self-funded product. Sometimes looks like a managed care organization that is organized similarly to a PPO in that physicians do not receive capitated payments, but the plan only allows patients to choose medical care from network providers. If a patient elects to seek care outside of the network, then he or she will usually not be reimbursed for the cost of the treatment. Uses a small network of providers and has primary care physicians serving as care coordinators (or gatekeepers). Typically, an EPO has financial incentives for physicians to practice cost-effective medicine by using either a prepaid per-capita rate or a discounted fee schedule, plus a bonus if cost targets are met. Most EPOs are forms of POS plans because they pay for some out-of-network care.
People who belong to an EPO must receive their care from affiliated providers, and services rendered by unaffiliated providers are not reimbursed.
A "closed panel" PPO in which patients may only use a specified group of providers in order to receive benefits.
People who belong to an EPO must receive their care from approved providers (for example, certain doctors, hospitals, etc.). If a patient sees a doctor who is not on the list of approved caregivers, the insurance company either (1) will not pay the bill or (2) will make the patient pay a larger part of the bill than usual.
A term derived from the phrase preferred provider organization (PPO). However, where a PPO generally extends coverage for non-preferred provider services as well as preferred provider services, an EPO provides coverage only for contracted providers; hence, the term exclusive. Technically, many HMOs can also be described EPOs.
An EPO is a more rigid type of PPO that requires the insured to use only designated providers or sacrifice reimbursement altogether.
A health plan that has the characteristics of an HMO or PPO plan.
A health plan, such as Encircle EPO, that has similar characteristics to an HMO or PPO plan.
Hybrid managed care organization that is sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations. Back to the top of the page
A type of preferred provider organization (PPO) that requires the insured to use only the listed providers or to otherwise forfeit benefit reimbursement altogether.
Arrangement consisting of a group of providers who have a contract with an insurer, employer, third party administrator or other sponsoring group. Criteria for provider participation may be the same of those in PPOs but have a more restrictive provider selection and credentialing process.
provides coverage for services only from network providers