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In the United States, an exclusive provider organization (EPO) is a hybrid health insurance plan in which a primary care provider is not necessary, but health care providers must be seen within a predetermined network. Out-of-network care is not provided, and visits require pre-authorization.
This limit doesn't apply to out-of-network services. [20]) Because of the relatively high cost of HDHPs, the increased out-of-pocket costs can be burdensome especially for low income families. [21] As a way to try and offset the cost of care, HDHP policy holders may contribute to a health savings account (HSA) with pre-tax income. [22]
Examples included litigation between Aetna and a group of surgical centers over an out-of-network overbilling scheme and kickbacks for referrals, where Aetna was ultimately awarded $37 million. [25] While Aetna has led the initiative, other health insurance companies have engaged in similar efforts. [26]
How can you get the care you need from an out-of-network provider without blowing your budget?
In-network vs. out-of-network care Unlike Original Medicare, which allows you to see any doctor who accepts Medicare, if you choose a Medicare Advantage HMO, you're limited to in-network providers ...
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Unlike EPO members, however, PPO members are reimbursed for using medical care providers outside of their network of designated doctors and hospitals. However, when they use out-of-network providers PPO members are reimbursed at a reduced rate that may include higher deductibles and co-payments, lower reimbursement percentages, or a combination ...
Only limited services are covered outside the network—typically only emergency and out-of-area care. Most traditional HMOs were closed network plans. Open network plans provide some coverage when an enrollee uses non-network provider, generally at a lower benefit level to encourage the use of network providers.