EPO vs. PPO Health Insurance ???

[DMickey28]

Does anyone know the difference between EPO and PPO. We are needing to pick a new healthcare program with DH's new job and these are the two I am deciding between. They are with United Healthcare. We have had an United Healthcare Premium PPO for the last few years so I know how that works. It's the EPO that confuses me.

It states clearly that you DO NOT need to choose a PCP with the EPO. So as far as I can figure out with the EPO you NEED to use a In-Network doctor or the claim is rejected vs. with the PPO you get benefits but at a reduced rate for an out of network doctor.

The difference per month is almost $400. We just moved and only have a few doctors already. My OB is on the "In Network" list, as is the hospital I will deliever in. DH's cardiologist in MA is on the list. I spot checked a few local peds on my OB's recommend list and they are on the list as well so I know I won't have a problem finding a ped for the boys. The coverage otherwise is exactly the same as the Premium PPO which is very good.

Is there something I am missing? I am waiting for a call back from the Benefits Administrator at DH's new company to confirm I am getting this correct.

Thanks!

 

[hvsteve1]

There are basically three types of plans...PPO,EPO,HMO amd POS. POS is where you go to any doctor and submit a claim. An HMO is a physical facility or list of member doctors who are paid a "capitation" or annual fee to take care of you. PPO's allow you to go to a participating provider, who has negotiated a fee with the insurer, or an out-of-network provider who has not. You will normally have more coverage, such as only a co-pay, for in network while out-of-network may incur a deductible and copay, but you will be covered. An EPO is a kind of newer animal as doctors have a similar deal to those in-network with a PPO but you have NO coverage if you go out of network, similar to an HMO. All plans will pay in an emergency situation where an in-network provider or hospital is not avaialble. Considering the price difference, you may prefer the EPO if all the doctors and hospitals you would normally use are in the network. Whatever you do, if your company has a health savings account, put as much in as you are able. This will give you pre-tax savings in the event you want to go out of network for some medical care as well as any deductibles and co-pays you may have.

 

[hmansure]

It states clearly that you DO NOT need to choose a PCP with the EPO. So as far as I can figure out with the EPO you NEED to use a In-Network doctor or the claim is rejected vs. with the PPO you get benefits but at a reduced rate for an out of network doctor.

Is there something I am missing? I am waiting for a call back from the Benefits Administrator at DH's new company to confirm I am getting this correct.

Thanks!

Basically, an EPO is a much smaller PPO. EPO insurance plans offer a limited number of providers who offer large discounts on their rates (hence the large differential on the premium you are being quoted). As long as you are comfortable using their network you'll be okay from an out-of-pocket expense perspective. One of the biggest drivers of cost for health plans today is their out-of-network (OON) expense. By virtually eliminating the OON expense you're seeing another reason for the differential in the premium.

 

[mickeyboat]

You should be able to get a list of the benefits for each and compare them side by side.

EPOs are being encouraged for employers these days. They are much cheaper than PPOs and employees often get great additional benefits, such as health club membership reimbursement.

 

[Bowldawg]

My wife and I are in the exact situation you are in. Everything I have read on here is what I was told by the UHC rep. All of our doctors are "In Network" so I like the plan and the $400 per month savings. While the Co-Pays are higher and the family deductible is more, that $400 savings can pay for a lot of co-pays. If you aren't always sick, this is a good plan in my opinion and is the one we've chosen.

Hope this helps!

M

 

[Hardy]

We have been on an EPO plan with united healthcare for almost 2 years. I have not come across a situation yet where I've had a doctor that wasn't covered. It's always a worry to me, but it was a lower premium cost, lower copay, lower deductible, lower out of pocket max....really a no-brainer compared to the ppo we switched from. My son has had some recent health stuff and had to have 3 mris, at an estimated (hopefully high) cost of 15000. I am happy that my responsibility is only 10% vs 20% on our old ppo. The good thing is in almost any situation you can verify ahead of time everything is covered, except in emergency situations, which I still believe will be covered bc it is an emergency. Where we live the carilion system is the major one here and everyone takes united healthcare. If you are looking at united vs united as we did, I couldn't find a single doctor I was interested in that wasn't covered under both.

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