What Are EPO Health Insurance Plans?

What Are EPO Health Insurance Plans?

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A comprehensive health insurance plan is beneficial regardless of your overall health and medical history. Health insurance helps pay for routine care, like an annual checkup, as well as emergency procedures, hospitalization, prescription medications and other forms of care that can be expensive when paid out-of-pocket.

Choosing the right health insurance plan for your needs is often easier said than done. There are multiple types of health insurance available, including an exclusive provider organization (EPO) plan.

What Is an EPO?

An EPO plan is a type of health insurance that helps pay for medical care, but only if it’s from doctors and hospitals within the plan’s network.

When you get medical treatment in-network, the insurance company pays for a portion of the bill, and you pay what’s left depending on your deductible, coinsurance and out-of-pocket max.

A deductible is the amount you pay for covered services before your health insurance plan starts to help pay for your care. Coinsurance is the percentage of covered health insurance costs you pay after you pay your deductible amount. Your out-of-pocket maximum is the most you pay for your health care for the year.

An EPO doesn’t pay for out-of-network care. If you receive services out-of-network, you’re responsible for covering the entire cost, except for emergency medical care.

An EPO is the second most common type of health plan in the Affordable Care Act (ACA) marketplace. EPO plans make up 31% of all plans selected in the ACA are EPOs, second only to health maintenance organization (HMO) plans, according to a Forbes Advisor analysis of ACA plans.

How Does an EPO Health Plan Work?

An EPO health plan allows you to get medical treatment from providers and facilities that contract with the health insurance company. Those providers and health care facilities are considered “in-network.” The insurance company agrees to pay these doctors a certain amount for medical treatments and services.

When you get in-network care, the health insurance company covers the biggest portion of the cost. You pay the remaining balance in the form of a deductible, copayments and coinsurance (depending on the plan). A copayment is a set amount you pay for doctor visits and prescriptions after you pay your deductible.

One of the benefits of EPO insurance is that you don’t need a referral to see specialists. However, you must choose a specialist in the EPO’s network for the insurer to cover the visit.

Another thing to know about EPO health insurance is that pre-authorization may be required before the insurance plan covers certain medical procedures and treatments. From the insurance company’s perspective, a pre-authorization limits unnecessary care.

How Much Does an EPO Health Insurance Plan Cost?

An EPO plan costs an average of $436 a month for a 30-year-old. See more average below based on age, individuals, couples and families.

EPO plans cost slightly more than an HMO plan and much less than a preferred provider organization (PPO).

Cost of EPO vs. HMO vs. PPO

The cost of health insurance is based on a few factors, including your age, tobacco use, plan tier and dependents. In general, older people and tobacco users pay the highest rates for an ACA marketplace plan, as well as people with multiple dependents.

The cost of EPO insurance also depends on how you purchase the policy. For example, if your employer offers EPO health insurance, the cost is lower because your employer subsidizes a portion of the health insurance premium.

On the other hand, buying a private EPO plan through the health insurance marketplace will be more expensive because you pay for 100% of the premium. But government subsidies based on your income and family size can help cut that cost, if you qualify.

The only way to know how much you will pay for an EPO plan is to get quotes from insurance companies or go to the marketplace at Healthcare.gov.

EPO Pros

  • More affordable monthly premiums: The cost of an EPO health insurance plan is generally less expensive than a PPO plan.
  • Referrals not required: You don’t need a doctor referral to see a specialist, like a cardiologist or physical therapist.

EPO Cons

  • Out-of-network care is not covered: Out-of-network care is not covered under EPO plans, except for emergency care. If you want to see a doctor that is not in-network, you have to pay the full medical bill.
  • Can have high out-of-pocket costs: Some EPO plans have high out-of-pocket costs, like a deductible and coinsurance, which can increase the cost of coverage. However, it depends on the specific plan and tier you select.

EPO vs. HMO

An HMO plan and an EPO both require you to get medical treatment from an in-network provider. The insurance company won’t cover any medical treatment received out-of-network with either plan.

If you have an HMO, you’re required to work with a primary care provider, and you need a referral to see a specialist. An EPO allows you to manage your own care and referrals aren’t required.

In terms of cost, EPO plans are usually more expensive than HMOs, given that they offer slightly more flexibility. HMO plans can be a good option if you’re looking for the lowest cost plan and don’t mind working with a physician to coordinate your care.

EPO vs. HMO differences

EPO vs. PPO

A PPO plan offers the greatest flexibility to see any doctor you want, whether they are in-network or out-of-network.

Your insurance company pays the highest amount for in-network care and a smaller percentage for out-of-network care, so PPO members pay more for out-of-network care. In contrast, an EPO plan does not pay for any portion of out-of-network care (except in emergency situations).

Like an EPO plan, PPO plans don’t require you to work with a primary care provider or get a referral to see specialists. But due to the increased flexibility and higher levels of coverage, PPO plans are typically more expensive than EPO plans.

EPO vs. PPO differences

EPO vs. POS

Point of service (POS) health plans, which aren’t common, are a hybrid between a PPO and HMO plan.

With a POS plan, you must work with a primary care provider who oversees your medical care, and in most cases, referrals are required to see a specialist (like an HMO). But POS plans allow you to get treatment from an out-of-network provider and have a portion of the cost covered (like a PPO).

Compared to an EPO plan, POS plans often have smaller networks with fewer doctors and facilities. Therefore, the cost of an EPO plan is often slightly more expensive than a POS plan, but it depends on factors like the plan tier and out-of-pocket costs. POS make up a small portion of health plans, so you may have trouble finding one.

EPO vs. POS differences

Who Should Get an EPO health insurance plan?

An EPO health insurance plan can be a good option if you don’t want the hassle of getting referrals and want to manage your own care without the help of a primary care provider. It’s also a good choice if you’re looking for a plan with some flexibility but don’t want to pay the highest premium for a PPO plan.

Keep in mind that an EPO plan doesn’t provide any coverage for out-of-network care. If you want the freedom to choose any doctor or hospital you want or if you currently work with providers that are not in the EPO’s network, an EPO plan might not fit your family’s health insurance needs.

EPO Health Insurance Frequently Asked Questions

Does an EPO cover out-of-network care?

No, an EPO health plan does not cover out-of-network care unless you’re getting urgent or emergency medical treatment. If you receive care from a doctor or facility that is not in the EPO’s network, you are required to pay the bill without help from health insurance. Unlike a PPO plan, EPO plans do not have cost-sharing for out-of-network care.

Do you need a primary care physician if you have an EPO?

If you have an EPO insurance plan, you don’t need to work with a primary care physician. You have the flexibility to manage your own care and choose your own doctors. Because primary care visits are not required, you might also be able to expedite your treatment by making an appointment with a specialist right away.

Do EPOs require a referral to see a specialist?

No, you don’t need a referral to see a specialist if you have an EPO insurance plan. You can make appointments and choose specialists on your own without needing to see your primary care provider first. However, you must choose in-network specialists. The visit won’t be covered otherwise.


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