Exclusive Provider Organization Analysis

Decent Essays
In the organization that I am employed with, they offer Blue Cross Blue Shield of Texas; an Exclusive Provider Organization or (EPO) plan. There are three different tiers to choose from all with different plan benefits. Based on my healthcare needs I chose the tier with the benefit plan that has a lower cost-sharing and deductible, as a result the monthly premium is higher. Benefits offered and covered services under this EPO managed health plan provides for the payment of benefits only when the members utilize providers in the Blue Choice Network (EPO, n.d.). Contracted providers including physicians, specialty care providers, hospitals are those that provide the health care services at negotiated contracted rates and the only ones the members and use for healthcare. Most providers can be…show more content…
For instance, and exclusion would be bariatric surgery for weight loss or infertility, limitations would be only one mammogram allowed in a twelve month period. Maximum amount this plan for a member in its lifetime is one million dollars. For example if a patient is hospitalized for a long period of time, the lifetime maximum could be met easily, leaving the patient to find alternate health coverage (Definition of Health Insurance Terms, n.d.). Equally important to the cost is the services of a primary care physician. Providers that are the PCP of the member can determine if specialist are needed. Benefits for specialists are covered under the plan, however members must consult with their PCP for initial service to see if follow-up with specialist or other healthcare provider are needed. Blue Cross Blue Shield of Texas depends on PCP’s for medical records and letters of medical necessity to insure the member is receiving health care benefits that are medically necessary or otherwise. (Blue Cross Blue Shield of Texas,
Get Access