Health insurance policies often have a health insurance network in which you must utilize their medical staff to be covered. Different types include HMO, PPO, and EPO. Of these types, an Exclusive Provider Organization (EPO) is the most common health insurance network available through employers.
What is an Exclusive Provider Organization (EPO) Health Plan?
Exclusive provider organizations, or EPOs, are health insurance plans where you must use the services of doctors, hospitals, and other providers within the specified network. You will not be covered for any costs you incur when you see a doctor outside of that network.
How Does an EPO Health Plan Work?
Managed-care plans such as an EPO give you some coverage for your medical costs as long as you visit a health care provider in the specified network. This includes hospitals, doctors, therapists, etc. Some costs will be your responsibility, such as copays and out-of-pocket expenses, but once your deductible is met, your insurance will most likely cover expenses beyond that.
EPO plans can be beneficial when you have to visit a specialist. You will have coverage as long as they are in the health network designated by your plan. If you visit an out-of-network provider, you will have to pay for the costs out of pocket. It is important to know that these charges may not count toward your deductible.
Advantages of an EPO
An EPO plan is typically in the mid-cost range regarding premiums, which are offset by the coverage amounts as long as you stay in-network for your health care providers. Unlike other health networks, you do not need to have one primary care physician selected, which is excellent for those who do not visit the doctor often. Additionally, you do not need a referral to see a specialist. However, you may need prior authorization and, of course, they should be in-network.
Disadvantages of an EPO
The most significant disadvantage of an EPO is constantly having to make sure the medical providers you are seeing are in the network, which can prove to be complicated depending on where you live. And, if you go out of network, you have to pay out of pocket. You will also have a deductible and possibly some co-insurance, so even though the premiums may be affordable, the overall cost may not be financially beneficial, depending on your circumstances.
EPO vs. Other Health Plans
It isn’t always easy to pick the best type of health insurance plan for you. Consider how EPO plans compare with PPO, HMO, and POS health insurance.
EPO vs. HMO
An HMO and EPO are very similar health network plans. The main difference is that you must select a primary care physician with an HMO. This means they have to refer you to a specialist if you need that type of care.
An EPO will allow you to see a specialist without a referral, though you might need authorization from the insurance company. Just remember, you will have a deductible and possibly co-insurance.
EPO vs. PPO
While an EPO provides zero coverage for health care outside of the network and only for in-network medical providers, a PPO is different. A PPO plan allows some coverage for out-of-network providers after your deductible is met. It is generally a percentage of the costs that they will pay.
If you are concerned about always being able to see an in-network provider, a PPO may be a better option for you.
EPO vs. POS
A POS plan is almost like a hybrid of all available health care network plans. You must select a primary care physician and have coverage for both in-network and out-of-network providers. You will need a referral to see a specialist. Also, a POS plan does not generally have a deductible, making the premiums less affordable.
A POS plan doesn’t require a primary care physician or referrals. It will only provide coverage for in-network health care providers. You will always have a deductible with an EPO plan.
Who Should Consider an EPO Health Plan?
When choosing between EPOs and other health plans, price, choice, and flexibility are often the key factors to compare. With an EPO, you can go directly to a specialist without a referral, and these plans have more affordable rates. For the specialist services to be covered, they must be in-network. If you think you can stay in-network and afford a middle-of-the-road premium, then an EPO could be a good choice.