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 your 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. However, a defining feature of EPOs is that you do not need to get a referral from your primary care physician in order to see a specialist. Other types of health insurance that require you to have a primary doctor (like an HMO) also require you to get a referral from your PCP for specialist visits; otherwise, the insurance company may not cover the visit.
An EPO plan often requires you to pay more out of pocket before your insurance starts covering your medical expenses, but EPOs may also offer lower monthly premiums because the providers in your network have contracts with your insurance company.
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 and other out-of-pocket expenses, but your insurance company will step in to cover more costs once you hit a certain level of spending, known as your deductible.
EPOs have a some key features you need know:
You likely need to select a primary care provider.
You don’t need a referral in order for your insurance to cover specialist visits.
The insurance company doesn’t usually cover costs from out-of-network providers you visit.
Visiting an out-of-network provider may require pre-authorization.
Seeing a specialist with an EPO
You do not need a referral to see a specialist with an EPO. This can make it easier to get the care you need, whenever you need it. At the same time, make sure to visit a specialist who is in your network, because your insurance company may leave you with the bill if you go out of network. A specialist visit may also have a higher copay or coinsurance compared to visiting your primary care physician.
EPO plans and out-of-network providers
An EPO insurance plan will not cover the expenses you incur from going to out-of-network providers. Your insurer may also require pre-authorization if you want to visit an out-of-network hospital. Without prior approval, your insurance likely won’t cover the hospital bill.
The big exception is that emergency care is covered even if it’s out of network. Because of the Affordable Care Act, also known as Obamacare, health insurance companies can’t charge more for out-of-network emergency care. However, your insurance will still only cover costs if you meet their definition of an “emergency.” Your spending also may not count toward your in-network deductible. Check the details of an individual plan to learn more of what’s covered.
An EPO may be fine for you if you mostly get routine health care and it’s always in-network, but you may have to pay out of pocket if you travel and visit a doctor outside your network. If you need to see a specialist, always make sure they’re in your network.
Related: What qualifies as emergency care under Obamacare
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 created by the Affordable Care Act.
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.
The cost of EPO plans
EPO plans generally offer middle-of-the-road premiums, but the exact costs will depend on where you live and the specific plan you have. In addition to the premiums, make sure to compare copays (both in and out of network), coinsurance, deductibles, and out-of-pocket maximums, which is the maximum you will ever pay before insurance starts covering 100% of your costs.
If you need help paying monthly premiums, consider a health insurance subsidy.
3 alternative to EPOs
There are only a handful of types of health insurance plans: EPO, HMO, PPO, and POS. They all have different benefits and costs, so which is best for you depends on your health care needs. Below are some key differences to know as you choose a plan.
Plan feature | HMO | PPO | EPO | POS |
|---|---|---|---|---|
Primary care physician | Required | Not required | Usually required | Required |
Out-of-network coverage | Only emergencies | Covered, but at a cost | Only emergencies | Covered, but at a cost |
Specialist visit coverage | By referral only | No referral needed | No referral needed | By referral only |
Pre-authorization required | No | No | Typically | Typically |
Relative premium cost | Lower | Higher | Middling | Middling |
EPO vs PPO
If you don’t like that an EPO restricts you to in-network doctors, consider a preferred provider organization (PPO). PPOs don’t require a primary care physician and you don’t need a referral to see a specialist. PPO insurance also covers at least some of the cost from visiting out-of-network providers, unlike an EPO. A PPO plan won’t cover as much of the cost with an out-of-network doctor, so you’ll still pay a higher price to go out of network, but you at least won’t pay the entire bill out of pocket. Premiums may 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 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, an HMO plan requires you 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 plans often have lower premiums than EPO plans.
Learn more about how HMO plans work.
EPO vs POS
A point of point-of-service-plan (POS) operates like a hybrid of the HMO and PPO plans mentioned above. A POS plan 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 middle-of-the road premium costs, similar to EPOs.
