What’s an EPO Health Plan?

For the past five years, CaliforniaChoice has been bringing EPO (Exclusive Provider Organization) health plans to our members. Today, we have more than a dozen EPO options spread out over all four Affordable Care Act (ACA) metal tiers – that’s Bronze, Silver, Gold, and Platinum options for you.

Curious about what an EPO really is and how it stands out from other health plans? Let’s dive into the details you need to know.

What is an EPO?

An EPO is a health plan that combines some of the benefits of an HMO (Health Maintenance Organization) plan with some of the benefits of a PPO (Preferred Provider Organization) plan.

Like an HMO, an EPO gives members access to a select network of doctors and hospitals. If you, your employees, and enrolled dependents go to an in-network provider, you have limited out-of-pocket costs. On the flip side, if you go outside the plan’s network, it offers limited or no benefits – and your out-of-network costs may be entirely out of pocket.

Like a PPO, you and your employees don’t need to get a referral from a Primary Care Physician to visit a specialist with an EPO, so long as the doctor is part of the EPO’s provider network.

You may find an EPO offers just what you and your employees want and need:

• Premiums can be more affordable than a PPO.
• When you want to see a specialist, you can self-refer to in-network specialists.
• The EPO coverage through CaliforniaChoice includes member access to two Cigna + Oscar networks: LocalPlus® and Open Access Plus. The focused Cigna LocalPlus network includes key doctors, specialists, and hospitals throughout the state. The Cigna Open Access Plus network gives members wider access to care. The national network includes 1,000,000+ doctors, specialists, and other professionals as well as 17,000+ hospital and clinical facilities. (Note: Cigna + Oscar coverage will end in 2024, as the carrier partnership is exiting the California Small Group marketplace in 2025.)
• Deductibles on EPO plans offered by CaliforniaChoice start at zero; doctor visit copays start at $35; Rx copays start at $15 for generics (for plan specifics, refer to CaliforniaChoice enrollment literature).

HMO vs. EPO

With an EPO, you and your employees can go directly to an in-network provider and get the care you need immediately. No referral is necessary. If you have an HMO, a primary care doctor referral is needed before you can schedule an appointment with a specialist. That means extra time and money.

EPO vs. PPO

With an EPO, you and your employees can go directly to an in-network provider and get the care you need immediately. No referral is necessary. With an PPO, you and your employees can go directly to any provider – in or out of network provider – to receive care. No referrals are necessary. An EPO will save you money as compared to a PPO.

Easy Enrollment

If you and your employees don’t have EPO coverage among your current plan options, you can easily add or move to an EPO at renewal. Ask your broker for details concerning the EPO options available to your group. (Options vary by region.)