Understanding Your Exclusive Provider Organization (EPO) Plan
- An exclusive provider organization (EPO) plan is one type of health insurance. Knowing how coverage works can help you make the most of your benefits.
An exclusive provider organization (EPO) plan is a type of health insurance that only covers the cost of in-network care. You'll have to pay out of pocket if you visit a health care provider or hospital outside the network, with the exception of emergency care.
How Do Exclusive Provider Organization (EPO) Plans Work?
If you have an EPO plan, you usually have to choose a primary care physician, or PCP. This person or practice is the health care provider you visit for general medical care and preventive care. If you need specialty care, you can visit the appropriate in-network provider. Unlike similar insurance policies, such as health maintenance organizations (HMOs), EPOs don't require a referral. However, you might have to get authorization to see an out-of-network provider.
EPOs usually have a higher deductible than other health plans, which means you need to cover more of the cost of your care before your insurance coverage begins. On the other hand, network contracts often help reduce your monthly premiums.
How Do You Sign Up for an EPO?
You can enroll in an EPO through your employer if it offers this type of health plan as a benefit. If you buy your own health care coverage, you can get an EPO through the insurance marketplace in your state during open enrollment, which occurs during November and December. You might be able to sign up for an EPO outside of open enrollment in the case of a qualifying life event, such as a new job, marriage or birth of a child.
Before moving forward with an EPO, consider comparing this plan to other common types of health plans to see which best fits your needs.
EPO vs. PPO
A preferred provider organization (PPO) is a good choice if you want to see any health care provider without worrying about network status. In most cases, you get a discount for staying in the PPO network but still receive coverage outside the network. The monthly premiums for PPOs tend to be higher than those for EPOs.
EPO vs HMO
As with an EPO, HMOs only pay your health care costs if you stay in the provider network. The difference between these two plan types is that an HMO requires a referral from your PCP if you need specialty care. Otherwise, you'll be responsible for the entire bill.
EPO vs POS
POS stands for point-of-service plan, which combines aspects of PPO and HMO plans. You select a PCP and need to obtain referrals for specialty care, but you have more flexibility to seek care out of network without significant extra expense. The costs of POS premiums are similar to those of EPOs.