Is an Exclusive Provider Organization (EPO) Plan Right For You?
Key Takeaways
An EPO can be more budget-friendly than a PPO but has restrictive coverage for out-of-network care.
An EPO has higher deductibles but lower premiums than most PPOs.
If you have in-network providers and don’t want high deductibles, you may want to consider an HMO plan.
You don’t need a primary care provider 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.
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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.
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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
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.
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.
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.
