Guide to EPO insurance

Insights:

Exclusive provider organization (EPO) plans have restricted provider networks but are often more affordable than other types of plans. 

Health insurance covers a wide range of health care services, like preventative care, diagnostic testing, and hospital stays. One of the health insurance plans available through your employer or health insurance marketplace is EPO insurance, which stands for the exclusive provider organization.

EPOs are less common than other plans like preferred provider organization (PPO) plans, which are mostly offered by employers. An EPO plan usually has lower premiums than a PPO, but it also limits which doctors you can see and you don’t have out-of-network benefits.

Learn more about EPO health insurance to see if this plan fits your needs.

What is exclusive provider organization (EPO) insurance?

An EPO plan is a type of health insurance plan that allows you to see medical professionals within a specific network. 

Your insurance company covers the cost of care you receive from qualifying providers and at facilities in the network. In addition to a deductible, EPO plans often have coinsurance, deductibles, and copayments, which are your responsibility. 

One of the best things about EPO insurance is that you generally don’t need a primary care physician referral to see a specialist. So, if you trip and sprain your ankle, you can make an appointment with an orthopedic doctor without visiting your primary care provider first. That’s different from a health maintenance organization (HMO), which requires referrals to see specialists. 

How an EPO plan works

When you have an EPO health insurance plan, your health insurance company pays for the treatment you receive from in-network physicians and hospitals. Providers and facilities contract with your insurance company for reimbursement. They file claims and your insurance provider pays for the cost of the treatment, minus your deductible or coinsurance. The health care providers then send you the medical bills.

Like all types of health insurance, your insurance provider starts paying for your care once you reach your plan’s deductible. Usually, the lower the deductible, the higher the premiums. 

Also, most treatments you receive out-of-network are never covered by your health insurance plan in an EPO. The only exception is emergency care. If you choose to see out-of-network providers, you’re responsible for paying for the service entirely out-of-pocket.

How to get an EPO plan

There are several ways that you can purchase EPO health insurance.

“A consumer can buy an EPO insurance plan through the Affordable Care Act (ACA) marketplace, through an insurance broker, through their employer, or directly from the insurance company,” says Michael Swartz, president of Health Karma, a virtual primary care platform.

Keep in mind that if you have group health insurance through your workplace, you can only enroll in an EPO if your employer offers one. EPOs aren’t nearly as common as HMOs, which are the most similar type of health plan, and HMO plans aren’t offered nearly as often as PPOs in the employer-sponsored health insurance market. 

Some insurance companies offer multiple EPO plans with varying coverage limits, deductibles, and coinsurance and/or copay requirements. Once you sign up and add dependents (if you have any), you’ll pay the first premium and your coverage takes effect.

What companies provide EPO plans

Lots of health insurance companies have EPO health insurance plans. Here are some of the most common EPO providers:

• Cigna
• Blue Cross Blue Shield (varies by state)
• Aetna
• UnitedHealthcare
• Oscar
• Kaiser Permanente

While EPOs are available from many popular health insurance companies, you may have limited choices when you actually buy a plan. For example, only certain health insurance companies offer EPO plans through the ACA health insurance marketplace. Similarly, if your employer has EPO insurance, they probably only provide one option.

EPO insurance cost

EPO insurance usually costs less than a PPO plan but more than an HMO plan. In fact, an EPO can be equated to a PPO/HMO hybrid because it offers more flexibility than an HMO but has more network restrictions than a PPO.

However, the cost of EPO insurance depends on a few factors, including your insurance company, your location, your policy’s coverage limit, and your deductible. 

In most cases, an EPO that you purchase through your employer will be cheaper than buying a private EPO through an individual provider or the ACA marketplace. Plans are also more expensive if you have dependents, like a spouse or children.

EPO advantages and disadvantages

Before you decide to purchase an EPO plan, it’s important to weigh the pros and cons. While some people can benefit from an EPO, it may not be the best choice for everyone.

“EPO health plans usually have lower rates, copays, and deductibles than PPO plans, and it gives you the freedom to schedule appointments directly with specialists,” says Swartz.

However, an EPO limits the doctors that you can visit. If you currently see a doctor that doesn’t contract with the EPO network, you’ll need to find another provider.

Here are some of the EPO pros and cons to think about as you shop for health insurance.

Pros:

• Premiums tend to be more affordable than PPOs
• Don’t need a referral to see a specialist
• Covers emergency care out-of-network

Cons:

• Most out-of-network treatment isn’t covered
• Not as common as other health plans
• The network can be small, depending on the insurance company

Alternatives of EPOs

If you’re thinking about buying an EPO plan, you might also compare an EPO to a PPO and HMO, which are the two most common types of health insurance. Here’s a look at the main differences between an EPO vs. PPO and an EPO vs. HMO.

EPO vs. PPO

“PPO plans are the least restrictive type of plan when it comes to accessing your network of providers and getting care from outside the plan’s network,” according to Swartz.

There are two major differences between EPO vs. PPO health plans. First, with a PPO plan, you’re allowed to seek medical care in-network or out-of-network. In-network care is covered in full and out-of-network care but at a higher cost to the member. 

Another difference between a PPO vs. EPO is the cost. Typically, PPO insurance premiums are more expensive than EPO plans because there’s greater flexibility in terms of network coverage.

Neither plan requires you to get a referral to see a specialist.

EPO vs. HMO

If you compare EPO vs. PPO health insurance, you’ll notice that HMOs are much more restrictive.

HMOs, require you to work with a primary care provider and get a referral to see a specialist, whereas an EPO health plan doesn’t require referrals. Like an EPO, HMOs only cover medical services received from in-network healthcare providers, not included emergency medical care.

In terms of EPO vs. HMO costs, HMOs are usually cheaper. EPOs are slightly more flexible and are therefore more expensive. However, the cost difference depends on several factors, including your insurance provider.

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