California health insurance  -  Health Reform Questions  -  EPO versus PPO

 

What's The Difference Between EPO and PPO Networks?

 

 

Many Anthem PPO members have received notification that their PPO plan is turning into an EPO.  This is especially important since the network size is already an issue. 

 

Blue Shield of California offers one of the only PPO's available now on the market. 

 

First...some credentials Please!....

 

 

 

 

 

 

 

 

You can quote Blue Cross EPO versus Blue Shield of California PPO here:

 

 

 

Read below for distinction between EPO's and PPO's.

 

Comparing the EPO and PPO Plans

As you quote the new Exchange and non-Exchange plans, you'll see some terms that might be new to you, especially on the network side.

 

Many people have an understanding of what a PPO is but much fewer could answer what is an EPO plan?

 

The EPO is now an important term since roughly half the State for certain carriers will have only have EPO's available to them depending on the carrier.

 

 

Let's understand the difference between the PPO and EPO before shopping the Covered California plans.

 

Definition of the PPO

PPO stands Preferred Provider Organization.

 

It basically provides a large list of doctors and hospitals that you can access directly in most cases and get preferred rates for covered benefits. 

 

It's essentially a big group discount on health care.

 

You can also go off that list and receive coverage but you should expect to pay much more out of pocket for these non-network providers.

 

A great deal of health care in a PPO setting is self-directed.

 

You typically can refer yourself out to specialists, etc and the PPO model provides the most flexibility.

 

 

So what is an EPO?

EPO or Exclusive Provider Organization

The EPO works like the PPO except for the fact that you are unable to go off the network aside from true emergency situations.

 

You must stay within the EPO network in order to get help from the carrier.

 

Usually, the EPO network is the same as the PPO in terms of doctors and hospitals but you should still double-check your doctors/hospitals with the new Covered California plans since all bets are off when it comes to networks in the new world of health insurance.

 

UPDATE: The Blue Shield Individual Family PPO plans have not have access to Blue Card since 2019

 

The EPO may allow you to access the Blue Card network for Anthem Blue Cross or Blue Shield of California which essentially extends member's benefits to out-of-State Blue Cross Blue Shield providers (called the Blue Card program).

Make sure to ask your doctors or hospitals what "Covered California plans they participate with" since there are different networks out there now. 

The new PPO versus EPO networks under Covered California

Some carriers may offer only PPO or EPO is respective area.

 

This is very different from before where a PPO plan was generally statewide.

 

A carrier may offer PPO in southern California and EPO in northern California or vice versa.

 

The plan name and description through our quote page will delineate which network a particular plan falls under and you will also have access to the provider directory through the quote page. You can access rates, benefits, and provider directories below.

 

 

The net net...

 

EPOs work like PPOs (self-referral, etc) but you do not have benefits outside the network other than true emergency. 

 

It's a half-way step between EPO and HMOs!

 

Again, there is absolutely no cost to you for our services.  Call 800-320-6269 Today!

 

Email us at help@calhealth.net and we can go through any questions or run your instant Quote including Covered Ca with tax credit calculation.  Thanks!