What is an EPO plan?

An Exclusive Provider Organization (EPO) is a managed care plan that only covers services provided by doctors, specialists, or hospitals in the plan’s network.

Danielle R.

Published December 22, 2020.

An EPO is an exclusive provider organization. The name is appropriate as EPOs require you to see only providers within their network.

EPOs work out special deals with healthcare professionals to maintain costs, which is good both for them and their customers. However, in the case of emergency situations, you could receive medical care out of network, but it might be subject to approval by the EPO.

An exclusive network of providers

Similar to HMOs and PPOs, your regular, medically necessary appointments will be covered within the specific network. In order to avoid paying out of pocket costs, make absolutely sure that you are using the correct in-network providers. Since EPO maintain their network to keep costs down, breaking the rules will mean your non-compliant services would not be paid for.

Although, it can be stressful to maintain and decide how you will organize that, you will save money in the long run for your due diligence. The important thing is to maintain contact with the EPO should there be services you need that they cannot provide in network. If your situation is explained and approved, you most likely will still get the care that you need.

Primary care physician and specialist's visits with an EPO

Many EPO plans required that you choose a Primary Care Physician (PCP), sometimes also called family doctor, general practitioner (GP) or your kids’ pediatrician. Your PCP will handle all your routine health care and will provide general medical care when needed.

Since medical care is only covered within the network, you are not required to get a referral to see a specialist. You may still need to be preauthorized for expensive services.

Just remember that every EPO has slightly different rules and it is imperative that you get informed accordingly, so as to not get stuck with hefty bills later.

Cost of an Exclusive Provider Organization plan

Since care coverage is limited to in-network providers, EPOs generally have lower monthly health insurance premiums and are cheaper than PPOs. You may still have to pay a deductible, and overall a higher out-of-pocket amount, but depending on your EPO and how extensive their network is, this is still an incredibly economical option.

The EPO will designate how much cost-sharing you will have to do, which will affect your total personal health insurance costs. Staying within network will always keep these costs down.

Is an EPO plan right for you?

If you are unsure what choice is right for you, think about your situation. Are you okay with having to stay within a certain set of providers or do you want more individual freedom? How do you feel about the cost sharing? Is the network near you extensive enough to meet your needs? Are you frequently away from home where there may be no network to provide medical care should you require it?

Altogether, health insurance is an important decision and if you are still unsure if an EPO is right for you, speak with a health insurance agent you trust.  You can usually buy an EPO health plan through your employer or on a marketplace

Different types of health insurance plans

The most common alternatives to EPOs are HMO and PPO plans.

Health Maintenance Organization (HMO) plans offer a network of health care providers, but generally limit coverage to medical care received from in-network providers. In addition, with an HMO, you will need to choose a Primary Care Physician (PCP) and get a referral before seeing any specialist.

A Preferred Providers Organization (PPO) plan lets you visit out-of-network specialists without referral, but at a higher cost. You will pay less if you use in-network doctors, hospitals, or providers.

There is no harm in shopping around for the best choice for you and your loved ones when it comes down to matters of your health and wellness.