Exclusive Provider Organization (EPO) plan is an example of managed healthcare plan. An EPO plan is a type of health insurance plan that helps pay for medical care, but only if it is from doctors and hospitals within the predetermined plan’s network, like in HMO plan. When you get medical treatment from an in-network provider, the insurance company pays for a portion of the bill, and you pay what’s left depending on your deductible, coinsurance and out-of-pocket maximum. It does not pay for out-of-network care. If you receive services out-of-network, you are responsible for covering the entire cost, except for emergency medical care. Unlike the HMO plan, you will not need to receive a referral in order to see a specialist. You will still have a chosen primary care physician (PCP).
How Does An EPO Plan Work?
An EPO plan allows you to get medical treatment from providers that contract with the health insurance company that provides you insurance. When you get in-network medical care, the health insurance company covers the biggest portion of the cost. You pay the remaining balance in the form of a deductible, copayments, and coinsurance. If you want to see a specialist, you are not required to have a referral from PCP. However, you must choose a specialist from the EPO’s network for the insurer to cover the visit. On the other side, pre-authorization may be required before the insurance plan covers certain medical procedures and treatments. From the insurance company’s perspective, a pre-authorization limits unnecessary care.
EPO Plan Costs
EPO plans cost a little more than an HMO plan and much less than a preferred provider organization (PPO). An EPO plan costs an average of $436 a month for a 30-year-old.
The cost of an EPO plan also depends on how you purchase the policy. For example, if your employer offers EPO health insurance, the cost is lower because your employer subsidizes a portion 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 cut that cost.
EPO vs. HMO
Both HMO and EPO plans require you to get medical treatment from an in-network provider. Be aware that the insurance company won’t cover any medical treatment received out-of-network with either plan. If you have an HMO plan, you are required to work with a primary care physician (PCP), and you need a referral to see a specialist. On the other hand, EPO does not require any referrals and you are allowed to manage your own care, even though you have chosen your PCP. Last, EPO plans are more expensive than HMO plans, because they give more flexibility.
For Whom Is EPO Plan Intended?
An EPO health insurance plan can be a good option if you don’t want the trouble of getting referrals and want to manage your own care without the help of a primary care physician. It is also a good choice if you are looking for a plan with some flexibility but don’t want to pay the highest premium for a PPO plan.
Keep in mind that an 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’s network, an EPO plan might not fit your health insurance needs.