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EPO (Exclusive Provider Organization)
 

An EPO is an organization of providers which includes Physicians, Hospitals, Pharmacies, Labs, etc. that have agreed to charge a discounted rate in accordance to the allowable charges set by the insurance carrier. The structure is similar to the HMO without the need of a primary care physician (PCP). Since there is no PCP, there is no need for a referral.

PPO (Preferred Provider Organization)
 

Similar to an EPO, a PPO is an organization of providers which includes Physicians, Hospitals, Pharmacies, Labs, etc. that have agreed to charge a discounted rate in accordance to the allowable charges set by the insurance carrier. Unlike an EPO, the PPO allows the member to receive services outside of this network subject to the conditions of the policy. This structure is similar to the POS without the need of a primary care physician (PCP) for services received in network. Since there is no PCP, there is no need for a referral.

The out-of-network portion is generally subject to an annual deductible before any reimbursement to the user. Once the deductible is reached, the member is usually responsible for their share of the coinsurance up to a stop-loss level. The coinsurance percentage can be as high as 50% and the stop-loss level, which is the threshold as to when the coinsurance no longer applies, can be as high as $20,000 or more. This coinsurance provision normally applies to each and every procedure as well as for each and every family member. Provider payments are subject to a 'usual, customary, and reasonable’, or UCR rate level which is based on the HIAA rates schedule. This schedule generally represents the amount the insurance carrier will pay for a procedure in a given region. The UCR level is a percentile that depicts a percentage of providers that charge within the schedule. This percentile can be increased to encompass a greater number of providers, thus allowing a higher amount of covered charges.

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