EPO, PPO How Does It Work?

Both Anthem Blue Cross and Blue Shield of California are offering EPO or PPO plans in select areas of California.  For example, in LA and Orange Counties, Anthem offers EPO only whereas Blue Shield offers PPO only.  

To further complicate the matter, each carrier treats crossover services differently.  As I am getting this question frequently, I want to clarify how this works.

For Anthem Blue Cross members:

If you have a PPO in 2014 and use services from an EPO provider, you pay per the terms of your PPO contract.  

If you have an EPO in 2014 and use services from a PPO provider, you will be treated as "in-network" but will have to pay for benefits at the higher Tier 2 price level (you get the lower Tier 1 price level with EPO Providers).


For Blue Shield members:

If you have a PPO in 2014, all EPO providers are in the PPO network so you can use the EPO providers the same as the PPO Providers.

If you have an EPO, you cannot use any PPO providers at all and if you do they are considered out of network and you have no coverage.  

As you can see there are major differences in how each Blue carrier treats the crossover of plan usage between PPO and EPO.  


Dave
www.davefluker.com

Comments

  1. can you clarify the difference between Anthem Blue Cross EPO and HMO? There is no PPO offered in my area. The EPO is about $50 more a month than the HMO and has a more extensive directory of doctors it seems. Does that account for the difference in pricing?

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  2. I hope you see this before end of day...

    "If you have a PPO in 2014 and use services from an EPO provider, you pay per the terms of your PPO contract. "

    Are you saying that EPO providers are "out of network" for PPO plan holders? I live in Riverside county, but all of my doctors are in Orange County. OC only has EPO plans, Riverside only has PPO plans. If I sign up for the Riverside PPO plan, will I be able to see my OC doctors "in network"?

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  3. With Anthem, EPO providers are in-network for PPO plan members, and conversely EPO plan members may use PPO plan providers at the higher Tier 2 pricing. Anthem has full crossover with Pathway network EPO-PPO and PPO-EPO for those areas where a subscriber in one play type sees a provider where only the other plan type is available.

    Blue Shield makes no such availability and will only allow PPO-EPO, but not EPO-PPO network usage.

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