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, such as annual checkups, as well as emergency procedures, hospitalizations, prescription drugs and other types of care that may be more expensive out-of-pocket.

Choosing the right health insurance plan for your needs is often easier said than done. There are several types of health insurance available, including the Exclusive provider Organization (EPO) plan.

What is EPO?

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

When you receive in-network care, the insurance company pays part of the bill, and you pay the rest based on your deductible, coinsurance and out-of-pocket max.

A deductible is the amount you pay for covered services before your health insurance starts to cover you. Coinsurance is the amount of health insurance premiums you pay after you pay your deductible. Your out-of-pocket cost is the most you pay for your health care each year.

EPO does not pay for out-of-network care. When you receive treatment outside the network, you are responsible for paying for everything, except for emergency medical care.

EPOs are the second most popular type of health plan in the Affordable Care Act (ACA) marketplace. EPO plans make up 31% of all plans enrolled in the ACA and EPOs, second only to health organization (HMO) plans, according to Forbes Advisor’s survey of ACA plans.

How Does the EPO Health Plan Work?

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

When you receive care online, the health insurance company pays a large portion of the cost. You pay the remaining costs such as deductibles, copayments and coinsurance (depending on the plan). A copayment is the amount you pay for a doctor’s visit after you pay.

One of the advantages of EPO insurance is that you do not need to send to see a specialist. However, you must choose a specialist in the EPO network so that the insurance provider will pay for the visit.

Another thing you should know about EPO health insurance is that pre-authorization may be required before the insurance plan can cover certain medical procedures and treatments. From the insurance company’s perspective, pre-authorization reduces unnecessary care.

How much does an EPO Health Insurance Plan cost?

The EPO plan costs about $436 a month for a 30-year-old. See details below by age group, individuals, couples and families.

EPO plans cost less than an HMO plan and less than a private provider organization (PPO).

The cost of EPO vs. HMO vs. P.P.O

The cost of health insurance depends on a number of factors, including your age, tobacco use, coverage area and dependents. In general, older people and smokers pay more for the ACA’s market plan, as do people with more dependents.

The cost of EPO insurance also depends on how you purchase the policy. For example, if your employer provides EPO health insurance, the cost is lower because your employer provides part of the health insurance.

On the other hand, buying a private EPO plan through the health insurance market is more expensive because you pay 100% of the cost. But government subsidies based on your income and family size can help lower the cost, if you qualify.

The only way to find out how much you will pay for an EPO plan is to get a quote from your insurance company or go to the Marketplace at Healthcare.gov.

Benefits of EPO

  • Low monthly payments: The cost of an EPO health insurance plan is usually less expensive than a PPO plan.
  • Shipping is not required: You do not need a referral from a doctor to see a specialist, such as a cardiologist or physiotherapist.

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 who is not in the network, you will have to pay the full cost of the treatment.
  • It may be cheaper out-of-pocket: Some EPO plans have high out-of-pocket costs, such as deductibles and coinsurance, which can increase the cost of coverage. However, it depends on the system and field you choose.

EPO vs. HMO

Both HMO and EPO plans require you to get medical care from an online provider. The insurance company will not cover any medical care received outside the network of any plan.

If you have an HMO, you need to work with a primary care provider, and you need a referral to see a specialist. EPO allows you to manage your care and referrals are not required.

In terms of cost, EPO plans are generally more expensive than HMOs, as they offer less flexibility. HMO plans can be a good option if you’re looking for the most affordable plan and don’t mind working with your doctor to coordinate your care.

Differences between EPO and HMO

EPO vs. P.P.O

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

Your insurance company pays more for in-network care and less for out-of-pocket care, so PPO members pay more for out-of-pocket care. In contrast, the EPO system does not pay for any part of outpatient care (except in emergencies).

Like an EPO plan, PPO plans do not require you to work with a primary care provider or be referred to see a specialist. But due to higher coverage and higher coverage, PPO plans tend to be more expensive than EPO plans.

Differences between EPO and PPO

EPO vs. POS

Point of service (POS) health plans, which are not uncommon, are hybrids between a PPO plan and an HMO.

With a POS plan, you must work with the primary care provider that manages your medical care, and in most cases, referrals must be made to see a specialist (such as an HMO). But POS plans allow you to get coverage from an out-of-network provider and have a portion of the costs covered (like a PPO).

Compared to an EPO plan, POS plans often have smaller networks with fewer doctors and locations. Therefore, the cost of an EPO plan is usually a little more expensive than a POS plan, but it depends on factors such as plan coverage and out-of-pocket costs. POS makes up a small percentage of health plans, so you may have trouble finding one.

EPO vs. POS difference

Who Should Get an EPO Insurance Plan?

An EPO health insurance plan can be a good option if you don’t want to go through the hassle of referrals and want to take care of yourself without the help of a senior care provider. It’s a good choice if you’re looking for a flexible plan but don’t want to pay the high premiums of a PPO plan.

Remember that the EPO plan does not cover any outpatient care. If you want the freedom to choose any doctor or hospital you want or if you work with providers that are not in the EPO network, the EPO plan may not fit your family’s health insurance needs.

EPO Health Insurance Frequently Asked Questions

Does EPO provide offline care?

No, the EPO health plan does not cover outpatient care unless you receive urgent or emergency care. If you receive treatment from a doctor or facility that is not in the EPO network, you have to pay the bill without the help of health insurance. Unlike a PPO plan, EPO plans do not have cost sharing for outpatient care.

Do you need a general practitioner if you have EPO?

If you have an EPO insurance policy, you do not need to work with a general practitioner. You have the opportunity to take care of yourself and choose your own doctors. Because a primary care visit is not necessary, you can speed up your treatment by making an appointment with a specialist right away.

Do EPOs need a referral to see a specialist?

No, you do not need a referral to see a specialist if you have an EPO insurance plan. You can make an appointment and choose a specialist yourself without needing to see your primary care provider. However, you should choose professionals in-network. This trip will not be discussed otherwise.