Understanding health insurance plans can be tough; with so many plan types, coverage restrictions, and unexpected costs, you can easily start to feel overwhelmed. But don’t worry: if you’ve ever wondered, “what is EPO insurance and how does it work?”, you’re about to find out everything you need to know about this type of insurance plan and if it’s right for you.
Free Health Insurance Comparison - Save up to 30%
No junk mail. No spam calls. Free quotes.
No Signup required
An exclusive provider organization (EPO), as opposed to an HMO, PPO, or POS, is a type of health insurance plan that only covers doctors, hospitals, and health care services in your network. This means that if you go to a doctor outside of your network, you’ll likely have to pay for the visit entirely out of pocket. The only exception is emergencies: you’re generally allowed to use providers outside of your network in an emergency, but the circumstances must fit your insurance provider’s definition of an emergency.
EPO insurance typically requires you to have a primary care physician, who treats your health and offers you preventative care. You would visit your primary health care physician in most cases, except for emergencies. A great feature about EPO insurance is that you generally don’t need a referral from your primary care physician to see a specialist, although they must be in your network. With other types of insurance plans, you’d need a referral from your physician first in order to visit a specialist, or your insurance provider may not pay for the costs.
With EPO insurance, you have to pay for part of your healthcare expenses (known as your co-pay) but your insurance provider will start to pay for more of your healthcare costs once you pass your deductible. Although EPO insurance generally has lower monthly premiums, costs like your co-pays, deductibles and out-of-pocket expenses can add up.
Free Health Insurance Comparison - Save up to 30%
No junk mail. No spam calls. Free quotes.
No Signup required
If you’re receiving your health insurance through your employer, you can choose an EPO insurance plan if they offer one. If you’re getting your health insurance through the marketplace set up by the Affordable Care Act, then you’ll be able to choose an EPO insurance plan during open enrollment. If you’ve had a qualifying life event like a birth or marriage, then you’ll be able to choose an EPO insurance plan during special enrollment.
EPO insurance is a great option if you’re looking for cost-effective insurance and wouldn’t need coverage out of your network. Because providers in your network have contracts with your insurance provider, the monthly premiums are lower than other types of insurance plans.
However, if you happen to need coverage outside of your network and don’t have pre-authorization from your provider, your healthcare costs could skyrocket as you’ll be on the hook for the entire bill.
EPO insurance plans are considered middle-of-the-line insurance, with monthly premiums that are higher than HMOs but lower than PPO rates. You are limited to your network in terms of providers, so if you need specialized healthcare or want flexibility, you might prefer a different type of insurance plan.
Free Health Insurance Comparison - Save up to 30%
No junk mail. No spam calls. Free quotes.
No Signup required
If you’re looking for affordable health insurance, access to specialists, and wouldn’t need out-of-network coverage, EPO insurance is a great option. The good news is the open enrollment period allows you to shop around and find the best plan for your health and needs; you can assess the network coverage and review the costs to ensure an EPO insurance plan is right for you before committing.
Lauren Lewthwaite Lauren Lewthwaite has been freelance writing for almost five years writing content that ranges from health to insurance and everything in between. Lauren is also a trained translator in French and English and is a dog-mom to an adorable Australian Shepherd.
