The Truth About EPOs: A More Affordable Healthcare Option

February 18, 2021

In North Carolina right now, there is a high-quality, more affordable health insurance option available to big corporations who pay their own insurance claims, but not to individuals or small businesses who can’t self-fund.

The reason why? Government regulations.

That’s right: government regulations are preventing families from potential double-digit premium decreases. 

The plans are known as an EPO or “Exclusive Provider Organization.” By some estimates, these plans could save small businesses, workers and their families, close to 20 percent on their premiums while also improving the quality of care-coordination.

Here are the facts:

  • FACT: EPOs can offer significant premium savings. Estimates by the state’s largest insurer show that small businesses, workers and their families could save up to 19 percent on an EPO plan.
  • FACT: Big self-funded businesses are already saving up to 20 percent a month on their medical costs through a new EPO plan that launched at the start of the year.
  • FACT: Big hospitals in North Carolina are already participating in EPO plans.
  • FACT: 39 other states across the country offer EPO plans to small businesses and individuals, which makes those states more attractive for new jobs and employers.

Here are the myths:

  • MYTH: EPOs don’t have out-of-network coverage.
    • TRUTH: EPOs have out-of-network coverage for emergency care.
  • MYTH: EPOs don’t cover essential health benefits.
    • TRUTH: EPOs are ACA-compliant and cover all essential health benefits and pre-existing conditions.
  • MYTH: EPOs don’t have consumer protections.
    • TRUTH: The same consumer protections that apply to other ACA plans apply to EPOs.
  • MTH: EPOs don’t have an adequate network of doctors.
    • TRUTH: EPOs are subject to the same network adequacy standards as other ACA plans

EPOs are a quality, affordable insurance option that most other states offer as another option to their small businesses and individuals. Because of North Carolina regulations, we don’t.

That must change. If EPOs are good enough to save big corporations millions in health care costs, they are good enough for you too.


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