EPO stands for Exclusive Provider Organization. In an EPO managed care plan services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).

The insurance company pays for a portion of the bill when you get medical treatment in-network and you pay the balance depending on your deductible, coinsurance and out-of-pocket max.

A deductible is the amount you pay for covered services before your health insurance plan starts to help pay for your care. Coinsurance is the percentage of covered health insurance costs you pay after you pay your deductible amount. Your out-of-pocket maximum is the most you pay for your health care for the year.

An EPO doesn’t pay for out-of-network care. If you receive services out-of-network, you’re responsible for covering the entire cost, except in an emergency.

An EPO is the second most common type of health plan in the Affordable Care Act (ACA) marketplace. EPO plans make up 31% of all plans selected in the ACA. The most popular is health maintenance organization (HMO) plans.


How Do EPOs Work?

An EPO health plan allows you to get medical treatment from providers and facilities that contract with the health insurance company. They are considered “in-network.” The insurance company agrees to pay these doctors a specific amount for medical treatments and services.

When you get in-network care, the health insurance company covers the biggest portion of the cost. You pay the remaining balance in the form of a deductible, copayments and coinsurance (depending on the plan). A copayment is a set amount you pay for doctor visits and prescriptions after you pay your deductible.

One of the benefits of EPO insurance is that you don’t need a referral to see specialists. You must however choose a specialist in the EPO’s network for the insurer to cover the visit.

EPOs may require a pre-authorization before it will cover certain medical procedures and treatments. This limits unnecessary care as far as the insurance company is concerned.

The cost is based on factors such as age, tobacco use, plan tier and dependents. Older people and tobacco users generally pay the highest rates, as well as people with multiple dependents.

The cost of EPO insurance also depends on how you purchase the policy. As with all other insurance policies, if your employer offers the health insurance, the cost is lower because they subsidize a portion of the premium. Conversely, if you buy a private EPO plan through the health insurance marketplace, it will be more expensive because you pay for 100% of the premium. But government subsidies based on your income and family size can help cut that cost, if you qualify.

Calculating the cost of your EPO plan will involve getting quotes from insurance companies or going to the marketplace at Healthcare.gov.

EPO Pros & Cons

  • More affordable monthly premiums:  EPO health insurance plan is generally less expensive than a PPO plan.
  • Referrals not required: You don’t need a doctor referral to see a specialist, like a cardiologist or physical therapist.
  • Out-of-network care is not covered: Out-of-network care is not covered under EPO plans, except for emergency care. If you want to see a doctor that is not in-network, you have to pay the full medical bill.
  • Can have high out-of-pocket costs: Some EPO plans have high out-of-pocket costs, like a deductible and coinsurance. depending on the specific plan and tier you select, the cost of coverage will increase..


Who Should Get an EPO health insurance plan?

An EPO health insurance plan can be a good option if you don’t want the hassle of getting referrals and want to manage your own care without the help of a primary care provider. It’s also a good choice if you’re looking for a plan with some flexibility but don’t want to pay the highest premium for a PPO plan.

Keep in mind that an EPO plan doesn’t provide any coverage for out-of-network care. If you want the freedom to choose any doctor or hospital you want or if you currently work with providers that are not in the EPO’s network, an EPO plan might not fit your family’s health insurance needs.


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