What is an exclusive provider organization (EPO)?

A health insurance plan that only covers doctors within your network, but gives you freedom to go straight to a specialist when you need it

Derek Silva

Derek Silva

Published August 29, 2019

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KEY TAKEAWAYS

  • EPO plans only cover the cost at doctors or health providers that are within your network

  • Emergency care is covered, even if it’s out of your network

  • You do not need a referral if you want to see a specialist with EPO insurance

  • An EPO is a hybrid between an HMO and PPO plan

An exclusive provider organization, or EPO, is a health insurance plan that only allows you to get health care services from doctors, hospitals, and other care providers who are within a certain network. Your insurance will not cover any costs you get from going to someone outside of that network. The only exception is that emergency care is usually covered.

Many EPO insurance plans require you to select a primary care physician (PCP). A PCP is a doctor who can provide preventive care as well as treatment for minor and chronic illnesses. (You may also see people refer to a PCP as a general practitioner, family doctor, or pediatrician in the case of PCPs for children.)

Another defining feature of EPO plans is that you do not need to get a referral from your primary care physician in order to see a specialist physician. Other health insurance plans that require you to have a PCP also require you to get a referral from your PCP if you want the insurance company to pay for a visit to a specialist.

While an EPO restricts your health care options to the providers in your local network, this usually means you get lower monthly premiums because the providers in that network have contracts with your insurance company. On the flip side, an EPO health insurance plan often requires you to pay more out of pocket before your insurance starts covering your medical expenses.

In this article:

How an EPO plan works

An EPO is a type of managed care plan, which means that your health insurance plan will cover some of your medical expenses as long as you visit a health care provider — doctor, hospital, or other place offering health care services — within a particular network. You will have to pay for some of the cost on your own, through copays, but your insurance company will step in to cover some of the costs once you hit a certain level of spending, known as your deductible.

EPO plans and out-of-network providers

There are several types of managed care health insurance plans, and they differentiate themselves largely on whether you can go to out-of-network providers and how much your insurer will pay for if you do go out of network.

An EPO insurance plan will not cover the expenses you incur from going to out-of-network providers. This probably isn’t a big deal if you’re just getting care near home, but consider that you may have to pay out of pocket if you travel somewhere and want to visit a doctor outside your network.

The big exception is that emergency care is covered. According to the Affordable Care Act, also known as the ACA or Obamacare, health insurance companies cannot charge you higher copayments or coinsurance for out-of-network emergency care. So if you need to take an ambulance or be admitted to a hospital because of an emergency, an EPO will cover the costs.

However, your insurance will not cover the costs unless they are for an emergency. Your out-of-network expenses also may not count toward your normal deductible. If you want to make an out-of-network hospital stay in a non-emergency situation, you likely need to get approval from your insurer beforehand. Without prior approval, your insurance likely won’t cover the hospital bill. Check the details of an individual plan to learn more of what’s covered.

Seeing a specialist with an EPO

Another selling point with EPO plans is that you do not need a referral to see a specialist. Other plans that require you to choose a primary care physician usually don’t cover the cost of seeing a specialist unless your PCP specifically refers you to that specialist. At the same time, seeing a specialist may leave you with higher copays or coinsurance.

The cost of EPO plans

In order to get insurance coverage with an EPO, you will need to pay a monthly premium, just like you do for other types of health insurance. The cost of your premium depends on where you live and the specific plan you have, but EPO plans generally offer middle-of-the-road premiums.

One consideration as you look at premium costs is what kind of plan you’re getting. Cheaper insurance is often an HMO plan, which is more restrictive in many cases. More expensive plans often offer more freedom to visit out-of-network providers. The next section breaks down the common alternatives to EPO plans.

How to get an EPO plan

If you get group health insurance through your employer, you can only choose an EPO plan if your employer offers one.

If you don’t get insurance coverage through work, you can get an EPO through the marketplace. The Affordable Care Act created a marketplace where individuals can buy a health insurance policy. You will find EPO plans, so you can compare the costs and the specific plan benefits in order to choose the best option for you. In addition to your monthly premiums, make sure you consider the cost of copays (both in and out of network), coinsurance, deductibles, and the out-of-pocket maximum, which is the maximum you will ever pay before insurance starts covering 100% of your costs.

Whether you get a plan through work or the marketplace, you can only choose a new plan during Open Enrollment, a period from November to December when anyone can get an insurance policy. If you change jobs or experience a major life change, like the birth of a child, you may qualify for Special Enrollment, which allows you to enroll in a new plan outside of the Open Enrollment period.

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3 alternative health insurance plans

There are a number of health insurance plans available and they all offer slightly different costs and benefits. Here are three common types of health insurance plans that you may want to consider instead of an EPO.

EPO vs HMO

A health maintenance organization (HMO) is similar to an EPO in that you need to choose a primary care physician and your insurer will only cover health insurance costs if you go to an in-network provider. However, HMO plans require you need to get a referral from your primary doctor when you want to see a specialist. If you go to a specialist without a referral, your insurance will not cover any of the cost. (The only exception is seeing an OB/GYN.)

HMO health insurance plans often have the most affordable premiums.

Learn more about how HMO plans work.

EPO vs PPO

If you don’t like that an EPO restricts you to in-network doctors, consider a preferred provider organization (PPO). PPO insurance covers at least some of the cost from visiting out-of-network providers, though in-network doctors are more affordable.

PPO plans don’t cover as much of the cost with an out-of-network doctor, but you at least won’t pay the entire bill out of pocket. Premiums may also be higher with PPO than an EPO, but this varies by insurance company and by location.

Read more on PPO plans to help you decide between EPOs and PPOs.

EPO vs POS

A point of point-of-service-plan (POS) operates like a hybrid of the HMO and PPO plans mentioned above. POS plans may require you to choose a primary care doctor and you cannot see a specialist physician without a referral, just like an HMO. However, POS plans do offer more leeway to see out-of-network doctors and providers, like a PPO.

POS plans typically have more expensive premiums than HMO plans, but less expensive premiums than PPO plans.

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