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Is an Exclusive Provider Organization (EPO) Plan Right For You?

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Written by:
Andrew Hall

Key Takeaways

  • An EPO can be more budget-friendly than a PPOA Preferred Provider Organization (PPO) is a health insurance plan that doesn’t require you to get a referral from a primary care physician to see other doctors. Most PPOs allow you to see any doctors or providers in their network. but has restrictive coverage for out-of-networkA provider network is a group of doctors, hospitals and other specialists who agree with an insurance company to treat its clients. It’s usually less expensive for you to see a doctor within your provider network. care.
  • An EPO has higher deductiblesA deductible is an amount you pay out of pocket before your insurance company covers its portion of your medical bills. For example: If your deductible is $1,000, your insurance company will not cover any costs until you pay the first $1,000 yourself. but lower premiumsA premium is a fee you pay to your insurance company for health plan coverage. This is usually a monthly cost. than most PPOs.
  • If you have in-network providers and don’t want high deductibles, you may want to consider an HMOA Health Maintenance Organization (HMO) is a type of plan that uses a network of doctors, hospitals, and other providers to treat an insurance company’s customers. plan.
  • You don’t need a primary care providerA Primary Care Physician is a doctor that oversees and monitors your medical care under some plan types. PCPs also may be responsible for referrals to specialists. for in-network referrals.

FAQs

You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher, or your visit may not be covered.
In an emergency, your care is usually covered. Plans may vary on how they define an “emergency.” Often, an emergency visit requires you to be admitted by the ER you visit. Some non-emergency visits can be approved or pre-certified by your provider.
Some procedures can require a hospital stay, while others can be handled on an outpatient basis. Your primary care provider or the physician providing the service will determine whether you need to pre-certify. If your provider is in-network, they usually can help you coordinate the request with your insurance provider.