What Is an Exclusive Provider Organization?

What Is an Exclusive Provider Organization? text overlaying an image of someone picking up a health blockLike a Health Maintenance Organization (HMO), An Exclusive Provider Organization (EPO) health insurance plan only lets you see doctors and go to hospitals in its network. One good thing about the EPO health plans is that you usually don’t need a referral to see a specialist. This speeds up the process if you know what you need and don’t want to go through your primary care provider (PCP), but as an EPO member, you can’t get care from a provider outside of your plan’s network. Also, keep in mind that an EPO health insurance plan doesn’t cover services outside of its network. When deciding if an EPO health plan is right for you, there are many things to think about. Find out more about EPO insurance plans and how to get affordable coverage. 

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How EPOs Work

An EPO is a type of managed care plan, which means that your health insurance will cover some of your medical costs as long as you go to a doctor, hospital, or other place that offers health care services that are in a certain network. You will have to pay for some of the cost yourself through copays and other out-of-pocket costs, but once you reach your deductible, your insurance company will pay for more of the cost.

 

You do not need a referral to see a specialist if you have an EPO. This could make it easy to get the care you need when you need it. A specialist visit may also have a higher copay or coinsurance than a visit to your general care doctor. At the same time, make sure to visit a specialist who is in your network. If you go to a specialist who is not in your network, your insurance company may leave you with the cost. 

 

The same goes for a doctor or hospital that is not in the EPO’s network, you will have to pay for the costs yourself. The only exception is emergency care. However, your insurance will only pay for the costs if you have what they call an “emergency.” An EPO might be fine for you if you mostly get regular care and it’s always in-network, but if you travel and see a doctor outside your network, you might have to pay out of pocket. Make sure that any expert you need to see is in your network.

The Cost of EPOs

Premiums for EPO plans are usually in the medium range, but the exact cost will rely on where you live and what plan you have. The cost of health insurance depends on a number of things, such as your age, whether or not you smoke, the plan tier you choose, and the number of insured. In general, older people, people who smoke, and people with more than one child pay the most for an ACA marketplace plan. How you buy EPO insurance can also change how much it costs. For example, if your workplace offers EPO health insurance, the cost is lower because your employer pays a part of the health insurance premium.

 

On the other hand, if you buy a private EPO plan through the health insurance marketplace, it will cost you more because you pay 100% of the price. However, if you apply, government subsidies based on your income and the size of your family can help lower that cost. You can only find out how much an EPO plan will cost by getting quotes from insurance companies or by going to the marketplace.

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Pros and Cons of EPOs

All health insurance options have their own benefits and downfalls. Knowing both the good and the bad will help you decide if an EPO is right for you. 

Pros

  • Low premiums – Premiums for EPOs are usually less than those for Preferred Provider Organizations (PPOs) but more than those for Health Maintenance Organizations (HMOs).
  • Large provider networks – Most of the time, they have a bigger range of care providers than HMOs.
  • No referrals – You don’t need a referral to see a specialist. This saves you a copayment and the time it takes to see your general care doctor.
  • Options – You can get an EPO that doesn’t require you to have a primary care doctor or ask for a referral when you need to see an expert, but not every plan has this option.

Cons

  • Higher deductibles – With an EPO, you may have to pay more each year for your deductible, but your premiums will be cheaper.
  • No out-of-network coverage – If you get care from a provider who isn’t in your EPO’s network, your insurance company may not cover the services.

EPO vs PPO

If you don’t like how an EPO only lets you see doctors in its network, you might want to look into a PPO. PPOs don’t require you to have a primary care doctor, and you don’t need a referral to see an expert. Unlike an EPO, PPO insurance also pays at least some of the cost of going to a doctor who is not in their network. With an out-of-network doctor, a PPO plan won’t cover as much of the cost, so you’ll still pay more, but at least you won’t have to pay the whole bill yourself. The premiums for a PPO may be higher than those for an EPO, but this depends on the insurance company and where you live.

EPO vs HMO

With both an HMO plan and an EPO, you have to see a doctor who is in the plan’s network. With either plan, the insurance company won’t pay for any medical care you get outside of its network. You must work with a primary care provider if you have an HMO, and you need a referral to see an expert. An EPO lets you take charge of your own care and doesn’t require recommendations. Most of the time, EPO plans cost more than HMO plans because they give you a little more freedom. HMO plans can be a good choice if you want the cheapest plan and don’t mind working with a doctor to make sure your care is coordinated.

EPO vs POS

Point-of-service (POS) health plans are a mix of a PPO plan and an HMO plan. They are not very popular. With a POS plan, you must work with a primary care provider who is in charge of your medical care. To see a specialist, you usually need a recommendation from your primary care provider, just like with an HMO. Still, like a PPO, POS plans let you get care from a doctor who isn’t in their network and pay part of the cost.

 

POS plans tend to have smaller networks with less doctors and equipment than EPO plans. So, the cost of an EPO plan is often a little bit higher than the cost of a POS plan. However, this can rely on things like the plan tier and out-of-pocket costs. Few health plans have POS, so you might have trouble finding one.

Who Should Get An EPO?

An EPO health insurance plan can be a good choice if you don’t want the hassle of getting referrals and want to handle your own care without the help of a primary care provider. It’s also a good choice if you want some freedom in your plan, but don’t want to pay the most for a PPO plan. Remember that an EPO plan doesn’t cover care that isn’t given by a provider in its network. An EPO plan might not be right for your family’s health insurance needs if you want to be able to choose any doctor or hospital you want or if you already work with providers who are not in the EPO’s network.

How To Get An EPO

If your employer gives group health insurance, you can only choose an EPO plan if your employer has one. If you don’t get insurance through your job, you can get an EPO through the marketplace that the Affordable Care Act set up. Open Enrollment is a time from November to December when anyone can get an insurance policy. This is the only time you can choose a new plan. If you change jobs or have a big change in your life, like having a child, you may be able to sign up for a new plan outside of the Open Enrollment time. This is called “Special Enrollment.”

Working With EZ

There are a lot of different kinds of health insurance plans to choose from. So, it all comes down to what you want, how much money you have, and how healthy you are. The best way to find the right plan for you is to look into what each plan has to offer. So, you can get the most service for as little money as possible. Remember that health insurance is important even if you’re in good health most of the time. You never know what could happen, so it’s best to be safe. To get started, just type your zip code into the box below or call 877-670-3557 to talk to one of our certified agents.

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