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Is an Exclusive Provider Organization (EPO) Plan Right For You?

If you’re not looking for a primary care provider, EPO may be right if the network fits.

Written by: Andrew Hall.

Key Takeaways

  • An EPO can be more budget-friendly than a PPOA Preferred Provider Organization (PPO) is a health insurance plan that doesn't require you to get a referral from a primary care physician to see other doctors. Most PPOs allow you to see any doctors or providers in their network. but has restrictive coverage for out-of-networkA provider network is a group of doctors, hospitals and other specialists that have an agreement with an insurance company to treat its clients. It's usually less expensive for you to see a doctor within your provider network. care.

  • An EPO has higher deductiblesA deductible is the amount you pay out of pocket before your insurance company covers its portion of your medical bills. For example: If your deductible is $1,000, your insurance company will not cover any costs until you pay the first $1,000 yourself. but lower premiumsA premium is a fee you pay to your insurance company for a health plan coverage. This is usually a monthly cost. than most PPOs.

  • If you have in-network providers and don’t want high deductibles, you may want to consider an HMOA Health Maintenance Organization (HMO) is a type of plan that uses a network of doctors, hospitals and other providers to treat an insurance company's customers. HMOs use a Primary Care Physician (PCP) to maintain your health and refer you to specialists. plan.

  • You don’t need a primary care providerA Primary Care Physician is a doctor that oversees and monitors your medical care under some plan types. PCPs also may be responsible for referrals to specialists. for in-network referrals.

What is an EPO plan?

An Exclusive Provider Organization (EPO) is a type of health plan that offers a local network of doctors and hospitals for you to choose from. An EPO is usually more budget-friendly than a PPO plan. An EPO can have lower monthly premiums but require you to pay a higher deductible when you need health care.

How does an EPO plan work?

EPO health plans are often more affordable than PPO plans if you choose a doctor or specialist in your local network. However, if you decide to get care out of your plan’s network, your medical care may not be covered, except in an emergency. An EPO plan does not require you to have a primary care provider to direct your care.

EPO v. PPO?

A Preferred Provider Organization (PPO) is a type of health plan that offers a more extensive network, so you have more doctors and hospitals to choose from. Your out-of-pocket costs are usually higher with a PPO than with an EPO plan. You are not required to have an in-network primary care provider for referrals with a PPO.

An EPO plan does not require you to have an in-network primary care provider to direct your care. Unlike a PPO, your network of providers is smaller with a PPO. Also, out-of-network care usually is not covered with an EPO. EPO out-of-pocket costs are typically less than a PPO plan but more than an HMO plan.

EPO v. HMO?

A Health Maintenance Organization (HMO) is a type of health plan that offers a local network of doctors and hospitals for you to choose from. An HMO usually has lower premium costs than an EPO. An HMO requires you have an in-network primary care provider to direct your care and referrals. In-network care with an HMO is not as flexible as an EPO, but a higher deductible allows smaller monthly premiums.

An EPO does not require you to have an in-network primary care provider to direct your in-network care. An EPO has higher monthly premiums but provides more flexibility for in-network coverage. EPO and HMO plans have high deductibles and do not cover out-of-network care

FAQs

What’s the difference between in-network coverage and out-of-network coverage?

You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher, or your visit may not be covered.

How does coverage work if I need to be admitted to the hospital?

In an emergency, your care is usually covered. Plans may vary on how they define an “emergency.” Often, an emergency visit requires you to be admitted by the ER you visit. Some non-emergency visits can be approved or pre-certified by your provider.

What is pre-certification?

Some procedures can require a hospital stay, while others can be handled on an outpatient basis. Your primary care provider or the physician providing the service will determine whether you need to pre-certify. If your provider is in-network, they usually can help you coordinate the request with your insurance provider.

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