What You Should Know About EPO Health Insurance Plans

  • In-network only: EPO health insurance plans only provide coverage for services at in-network providers, except in emergencies.
  • No PCP: You usually do not need a primary care physician with an EPO plan.
  • No referrals: You generally don’t need referrals to see specialists as long as they are in the plan’s network.

What is EPO Insurance Coverage?

“An Exclusive Provider Organization (EPO) will generally only pay for your care if you use the providers within the plan’s network, except in medical emergencies,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a national nonpartisan consumer health care advocacy organization.

The EPO won’t help pay for any services received out-of-network. The exception to this is emergencies or urgent care situations, when the EPO may help pay for services even if you are treated at an out-of-network facility. You may be able to get coverage at out-of-network providers outside of emergency situations if you contact your EPO for preapproval first.

How Does EPO Insurance Work?

With an EPO insurance plan, you’re only covered for the care you receive at in-network providers, except in emergencies or if you get preapproval from your insurance plan.

“Unlike in an HMO, in an EPO, you might not need a primary care provider’s referral to see a specialist, as long as you stay within the plan’s network,” Fish-Parcham says.

“You can check with the plan or with your state insurance department about a few exceptional circumstances when an EPO might pay out of network, such as if it does not have adequate provider availability in a given specialty area, or if you have received a ‘surprise bill’ from an out-of-network provider while in an in-network hospital.” Fish-Parcham adds that new federal rules about “surprise bills” go into effect in January 2022.

While referrals usually aren’t necessary with an EPO, you may need preapproval from your EPO provider before receiving many health services.

Costs can vary with EPO insurance plans, but as long as you use only in-network providers, your overall cost with an EPO should be less than the total cost of the services since your insurance provider will reimburse you for a percentage of the treatment you receive up to a certain level.

If you go out-of-network, you will need to pay the full cost of the services you receive, unless it’s during an emergency. Otherwise, you must receive preapproval from your insurance provider before getting treatment.

How Does EPO Differ From Other Types of Health Insurance?

An EPO is a hybrid between HMOs and PPOs, says Rick Louie, managing director of Hospital Pricing Specialists. “Similar to an HMO, an EPO requires members to stay within the network of physicians and hospitals that participate in the plan.” And like a PPO, an EPO has benefits where members do not need a referral to see specialists within their network.

Like an HMO, you’re expected to use only in-network providers in an EPO. If you go out-of-network, you will be responsible for the full cost of the services you receive, unless it’s during an emergency or you get preapproval from your provider. An EPO is different from a PPO, which provides more coverage for plan network providers, called “preferred providers.” You still get coverage at out-of-network providers in a PPO; you just have to pay more for the services received there.

With PPOs, you can usually choose to have a primary care provider if you want. With an HMO, you must have a primary care doctor you visit first and see to get referrals to specialists. With an EPO, you often do not need to have a primary care provider.

Since you don’t usually have a primary care physician in an EPO, you can often see specialists or get lab tests without needing a referral as long as you go to in-network providers.

You may need to get preapproval from your EPO provider for certain services before you can receive treatment, however. This is also true of HMO plans but not PPOs, which usually let you get treatment without preapproval.

How you pay also varies by insurance plan type. With an EPO, like an HMO, you usually pay a copay or flat fee for the services you receive. This is distinct from a PPO, which generally sets an annual deductible and may also have separate deductibles for hospital care and prescription medications.

What Are The Advantages and Disadvantages of EPO Insurance?

Like any type of insurance, there are benefits and drawbacks to EPO insurance:

Advantages Disadvantages
  • It does not require you to use a primary care physician.
  • You don’t need to get referrals to see specialists.
  • EPOs also generally have lower premiums than HMOs due to their higher deductibles.
  • They’ll often have lower monthly premiums but higher deductibles than PPO plans.
  • You must stay within the plan’s network if you don’t want to pay the full cost of your treatment.
  • There is no coverage for care received outside of your plan’s network unless you get preapproval or it’s an emergency.
  • EPO plans tend to have fewer choices of physicians.
Insurance and health care consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity products.

She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies, as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and healthcare consultant, now helping people understand the medical system. Since becoming an agent, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.