What are EPO health insurance plans? – Forbes Advisor

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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 an annual exam, as well as emergency procedures, hospitalizations, prescription drugs, 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 many types of health insurance available, including an Exclusive Provider Organization (EPO) plan.

What is 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 in-network medical treatment, the insurance company pays part of the bill and you pay what’s left, depending on your deductible, coinsurance and max.

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

EPO does not pay for out-of-network care. If you receive out-of-network services, you are responsible for covering the entire cost, except for emergency medical care.

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

How does the EPO health plan work?

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

When you get in-network care, the health insurance company covers most of the cost. You pay the balance in the form of deductibles, 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 advantages of EPO insurance is that you do not need a referral to see specialists. However, you must choose a specialist in the EPO network for the insurer to cover the visit.

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

How much does an EPO health insurance plan cost?

An EPO plan costs an average of $436 per month for a 30-year-old. See more averages 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).

Costs for EPO vs. HMO vs. PPO

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

The cost of EPO insurance also depends on how you buy the policy. For example, if your employer offers EPO health insurance, the cost is lower because your employer subsidizes part 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 100% of the premium. But government subsidies based on your income and family size can help reduce those costs if you qualify.

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

EPO professionals

  • More affordable monthly premiums: The cost of an EPO health insurance plan is usually cheaper than a PPO plan.
  • No referrals required: You don’t need a doctor’s referral to see a specialist, such as a cardiologist or physical therapist.

EPO Minus

  • Out-of-network care is not covered: Out-of-network care is not covered by EPO plans, except for emergency care. If you want to see an out-of-network doctor, you must pay the full medical bill.
  • There may be high out-of-pocket costs: Some EPO plans have high out-of-pocket costs, such as deductibles and coinsurance, which can increase the cost of coverage. However, this depends on the specific plan and tier you have chosen.

EPO vs. HMO

The HMO and EPO plan require you to get medical treatment from an in-network provider. The insurance company will not cover any medical treatment received out of network with either plan.

If you have an HMO, you are required to work with a primary care provider and need a referral to see a specialist. EPO allows you to manage your own care and no referrals are required.

In terms of cost, EPO plans tend to be more expensive than HMOs, given that they offer a little 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 doctor to coordinate your care.

EPO vs. HMO differences

EPO vs. PPO

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

Your insurance company pays the highest amount for in-network care and a lower 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 part of out-of-network care (except in emergency situations).

Like an EPO plan, PPO plans do not require you to work with a primary care provider or get a referral to see specialists. But because of the increased flexibility and higher coverage levels, PPO plans tend to be more expensive than EPO plans.

EPO vs PPO differences

EPO vs. POS

Point-of-service (POS) health plans, which are not common, are a hybrid between a PPO and an 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 (such as 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 such as plan level and out-of-pocket costs. POS makes 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 to have to get 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.

Note that the EPO plan does not 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 network, an EPO plan may not meet your family’s health insurance needs.

EPO Health Insurance Frequently Asked Questions

Does EPO cover out-of-network care?

No, an EPO health plan does not cover out-of-network care unless you are receiving urgent or urgent medical treatment. If you receive care from a doctor or facility that is not in the EPO 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 doctor if you have EPO?

If you have an EPO insurance plan, you do not need to work with a primary care doctor. You have the flexibility to manage your own care and choose your own doctors. Since no primary care visits are required, you may be able to speed up your treatment by making an appointment with a specialist right away.

Do EPOs require a referral to a specialist?

No, you do not need a referral to see a specialist if you have an EPO insurance plan. You can make your own appointments and choose specialists without the need to first consult with your primary care provider. However, you should choose online specialists. Otherwise, the visit will not be covered.


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