What is EPO insurance?

EPO stands for "Exclusive Provider Organization" plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits.

How does an EPO plan work?

Health insurance companies that offer EPOs only pay for providers and hospitals in their approved networks. Below, find the health insurance terms you'll need to understand fundamentals of EPO insurance:

• Network coverage. EPO plans partner with hospitals and doctors to provide the best possible care for plan members. These approved caregivers and facilities are referred to as “network providers” or “in-network providers.” It's important to note that EPO members are required to use in-network resources whenever possible for their care. However, these plans cover emergency services no matter who you see or where you go for service.
• Primary Care Physician. A primary care physician or family physician or PCP is a general practitioner who provides your routine health care. EPO plans don’t require plan members to have a designated, in-network PCP. However, it’s a good idea to have one to help you coordinate your medical needs.
• Copay: When you join an EPO network, you have to pay a copay. This might include $20 for a doctor visit or $100 for a trip to the emergency room, for example. See individual plan details to find out the copays for various services and providers.
• Deductible: Like other insurance plans, EPO insurance typically comes with a deductible. This is the amount that you pay to share the cost of your healthcare. For example, if you have a $500 deductible, you will pay the first $500 of healthcare in a given year. Typically, paying higher deductibles equates to lower monthly premiums.
• Coinsurance: Coinsurance plans split the cost between planned members and healthcare insurance companies. For example, if you have an 80/20 coinsurance agreement, your EPO insurance will pay 80% of the cost of care while you are responsible for the remaining 20%.

Your agent can help you understand how your EPO plan works and what it will cost you to receive care.

Benefits of an EPO plan

Lower costs

EPO insurance typically offers lower rates than other kinds of health insurance. As part of the contract, you agree to deal specifically with hospitals and doctors in a preapproved network. This can lower your rates because EPOs already have agreed what they will pay for various services. Your insurance carrier can achieve lower costs by negotiating reimbursement rates with these providers.

PCPs are not required

Unlike HMOs, EPO insurance does not require primary care physicians. This gives you more flexibility over your healthcare. For example, if you need to see a dermatologist or other specialist, you can make an appointment directly without going through your PCP.

Large network

EPO plans curate a large network of professionals from nearly every conceivable specialization. In fact, they have larger networks than HMO or PPO plans. This is one of the major benefits of EPO insurance.

EPO vs PPO plan

There are a few basic differences when comparing EPO vs PPO plans. With an EPO plan, a PCP is often needed but it’s not required, and out-of-network coverage can only be used for emergencies. a PPO plan requires a primary care physician while an EPO does not. However, you will often need a primary care physician to meet your health care needs. While a PPO allows out-of-network coverage at a higher cost, an EPO plan only allows out-of-network coverage for medical emergencies. Neither EPOs or PPOs require referrals in order for you to visit a specialist, distinguishing these two insurance plans from HMO's which do require referrals.

PPOs give you more freedom to seek the provider of your choice without any referrals needed. EPOs limit you two in network providers, but they also generally have access to a large network of doctors and facilities.

Additionally, EPOs typically cost less than PPOs when it comes to monthly insurance.

How much does an EPO plan cost?

How much you will actually pay for your EPO premiums and copays depends on where you live and the specific plan you choose. Typically, you will have to pay copays, deductibles and coinsurance. So, it's important to understand what you're signing up for before you make a final decision. However, you will have some of these same costs with most insurance plans that you choose.

Keep in mind that you need prior approval for hospitals and providers when you choose an EPO plan. Without prior approval, you could get stuck with paying the bill out of pocket.

EPO insurance FAQS

Does EPO require a referral?

No, with an EPO plan you don’t need a referral to see a specialist.

What is the downside of an EPO plan?

Although there are many benefits to working with PPO plans, there are also some inconveniences to consider. There are also a few downsides to choosing EPO insurance:

• You might have to switch your current PCP.
• You’re restricted to in-network providers.
• You are responsible for knowing which hospitals and providers are in network.
• You will need approval for test and expensive services

Is a PPO or an EPO plan better?

Only you can decide which plan is best for you and your family. Consider what you want for your healthcare plan. PPOs allow you to choose any doctor or hospital you wish to use for services. However, they are more expensive than EPO plans, which come with a large network of doctors and specialists and lower premiums.

An EPO plan may be right for you if:

• You do not want to get a referral to see a specialist.
• You want to receive a much lower negotiated rate with an EPO plan than you would with an HMO or PPO plan.

If you would like to apply for an EPO plan, but would like more details, please call one of our licensed agents at 1-855-849-4809 .

So now that you better understand how EPO insurance works, it's important to partner with the right company to find healthcare plans that fit your family's budget and needs.

Contact eHealth insurance today for assistance with EPO plans and other types of insurance to protect your family.

*Definitions may vary by plan provider. Please read the provider's Summary of Benefits.