Providence Personal Option and Providence Open Option (EPO) FAQs

• What does EPO mean?
• What are the EPO plans called?
• What is a personal physician/provider?
• How is my care managed?
• How can I find out who is a Providence Health Plan participating provider?
• How is this different from a PPO?
• What do member benefits look like on the EPO plans?
• What is an annual deductible?
• What is an annual out-of-pocket maximum?
• What are prior authorization requirements?
• How do you handle grievance and appeal processes?
• Who do we call for customer service for the EPO?
• How are members identified?
• How does out-of-area dependent coverage work under the EPO options?

EPO stands for "Exclusive Provider Organization." This is a fairly new industry term, and in our case, we are using it to define our new commercial line of business that has the following features:

• Closed panel — meaning you need to use participating providers to receive covered services unless you choose to use your Out-of-Plan benefit on the Open Option plan.
• Participating providers hold no risk (capitation or withholds). PHP pays participating providers a discounted fee-for-service payment instead.
• No primary care physician or provider (PCP) selection required
• “Personal physician/provider” selection encouraged through a lower member copayment
• No specialist referral requirement for in-plan providers
• Greater member cost sharing when using a provider that is not a personal physician/provider
• Medical management provided by PHP

We call our EPO plans Personal Option and Open Option. Personal Option is our standard EPO plan. For most covered services you are required to see a Providence Health Plan Personal Option participating provider. Open Option works just like Personal Option with the added option of receiving covered services from non-participating providers through what is called the "Out-of-Plan" benefit.

A personal physician or provider is similar to a PCP in that we are encouraging personal relationships between you and your physician. However, unlike an HMO, EPO members are not required to choose a personal physician/provider. In addition, a member can receive services from ANY personal physician/provider, not just the one they have selected and enjoy the personal physician/provider benefit (a flat member copayment per visit).

Your EPO plans continue to have low copayments for visits to a personal physician/provider for health screenings, women's annual exams, immunizations and other preventive measures. PHP continues with disease management programs to assist members and providers to get the most from available care.

Our EPO plans are called “Providence Personal Option” and “Providence Open Option.” Providence Health Plan keeps an up-to-date list of Personal Option and Open Option personal physician/providers (family practice, internal medicine, pediatrics, general practice and some obstetric/gynecology providers as noted in the directory), specialists and alternative care providers on our online Provider Directory. You also can call Providence Health Plan Customer Service at 503-574-7500 or 1-800-878-4445 for participating provider information or to have a paper copy of the provider directory sent to you.

PPOs traditionally allow members to access health care services outside of the network of contracted providers for a higher out-of-pocket expense. They also usually do not cover preventive services nor encourage use of an accountable personal or primary care physician.

Personal Option and Open Option member benefits have a copayment -- a flat dollar amount per visit -- for services provided by any participating personal physician/provider. Plans have a coinsurance for most other health care services; some plan designs have deductibles. Some custom plans may have different member cost sharing amounts for other health care services. See your Summary of Benefits for details.

An annual deductible is the amount of money that you need to pay for covered services each calendar year before Providence Health Plan will begin paying for coverage. The deductible will not apply to all covered services. For instance, if you receive services from a personal physician/provider, PHP will provide coverage for those services before your deductible is met. Likewise, any copayments you make for these services that are covered will not apply toward meeting your deductible. See your Summary of Benefits and Member Handbook for additional details.

An annual out-of-pocket maximum is the maximum amount of money that you need to pay for covered services in a calendar year. For example, suppose your annual out-of-pocket maximum is $750 per year. During the year, you receive $10,000 worth of covered services and your coinsurance for these services is 20 percent. That would mean you would need to pay $2,000 of $10,000 for these services while PHP covered the remaining balance – but, you would actually only need to pay $750 of this amount because you reached your out-of-pocket maximum.

PHP would cover the costs for the remainder of the calendar year in full for these services and subsequent services. The annual out-of-pocket maximum does not apply to all covered services. See your Summary of Benefits and Member Handbook for additional details and a list of services that do not apply to your out-of-pocket maximum.

When you see participating providers under your In-Plan benefit, your provider will take care of any prior authorization requirements, just like under an HMO plan. If you see a non-participating provider under your Out-of-Plan benefit or Out-of-Area Dependent benefit, you will be responsible for any prior authorization requirements. Those requirements are listed in your Member Handbook.

See Grievance and Appeals in your Member Handbook for details.

The Customer Service Team can be reached online, or you may call 503-574-7500 or toll-free 1-800-878-4445.

Personal Option and Open Option members are clearly identified with ID cards that have a distinctive look and clear product identification. New identification cards are sent to members as they come onto the EPO plans.

With all of the EPO options, you can cover a spouse and/or children who do not live with you. If your spouse and/or children live outside of the PHP service area, they can enroll as out-of-area dependents. Out-of-area dependents may see any provider, in or out of the service area. PHP will pay up to 80 percent of covered charges. PHP's payment is based on usual, customary and reasonable (UCR) charges. Charges that exceed UCR are your responsibility and these charges are not applied to the out-of-area dependent out-of-pocket maximum. To cover your out-of-area dependents, you must complete an application and send it to Providence Health Plans.