What Are EPO Health Insurance Plans? – Forbes Advisor


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A comprehensive medical insurance plan is useful no matter your overall health and medical history. Medical insurance helps pay for routine care, like an annual checkup, in addition to emergency procedures, hospitalization, prescription medications and other types of care that could be expensive when paid out-of-pocket.

Selecting the suitable medical insurance plan in your needs is usually easier said than done. There are multiple forms of medical insurance available, including an exclusive provider organization (EPO) plan.

What Is an EPO?

An EPO plan is a sort of medical insurance that helps pay for medical care, but provided that it’s from doctors and hospitals inside the plan’s network.

If you get medical treatment in-network, the insurance company pays for a portion of the bill, and also you pay what’s left depending in your deductible, coinsurance and out-of-pocket max.

A deductible is the quantity you pay for covered services before your medical insurance plan starts to assist pay in your care. Coinsurance is the proportion of covered medical insurance costs you pay after you pay your deductible amount. Your out-of-pocket maximum is essentially the most you pay in your health take care of the 12 months.

An EPO doesn’t pay for out-of-network care. When you receive services out-of-network, you’re accountable for covering the whole cost, apart from emergency medical care.

An EPO is the second commonest sort of health plan within the Inexpensive Care Act (ACA) marketplace. EPO plans make up 31% of all plans chosen within the ACA are EPOs, second only to health maintenance organization (HMO) plans, in response to a Forbes Advisor evaluation of ACA plans.

Coverage area

Offers plans in all 50 states and Washington, D.C.

Variety of providers in network

About 1.2 million

Physician copays start at


Coverage area:

Offers plans in all 50 states and Washington, D.C.

Variety of providers in network

About 1.7 million

Physician copays start at


Coverage area

Offers plans in all 50 states and Washington, D.C.

Variety of providers in network

About 1.5 million

Physician copays start at


How Does an EPO Health Plan Work?

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

If you get in-network care, the medical insurance company covers the most important portion of the price. You pay the remaining balance in the shape 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 among the advantages of EPO insurance is that you simply don’t need a referral to see specialists. Nevertheless, you should select a specialist within the EPO’s network for the insurer to cover the visit.

One other thing to learn about EPO medical insurance is that pre-authorization could also be required before the insurance plan covers certain medical procedures and coverings. From the insurance company’s perspective, a pre-authorization limits unnecessary care.

How Much Does an EPO Health Insurance Plan Cost?

An EPO plan costs a mean of $436 a month for a 30-year-old. See more average below based on age, individuals, couples and families.

EPO plans cost barely greater than an HMO plan and far lower than a preferred provider organization (PPO).

Cost of EPO vs. HMO vs. PPO

The associated fee of medical insurance is predicated on just a few aspects, including your age, tobacco use, plan tier and dependents. Basically, older people and tobacco users pay the best rates for an ACA marketplace plan, in addition to individuals with multiple dependents.

The associated fee of EPO insurance also is determined by how you buy the policy. For instance, in case your employer offers EPO medical insurance, the price is lower because your employer subsidizes a portion of the medical insurance premium.

Then again, buying a personal EPO plan through the medical insurance marketplace shall be costlier since you pay for 100% of the premium. But government subsidies based in your income and family size might help cut that cost, when you qualify.

The one method to understand how much you pays for an EPO plan is to get quotes from insurance firms or go to the marketplace at Healthcare.gov.

EPO Pros

  • More cost-effective monthly premiums: The associated fee of an EPO medical insurance plan is mostly inexpensive than a PPO plan.
  • Referrals not required: You don’t need a health care provider referral to see a specialist, like a cardiologist or physical therapist.

EPO Cons

  • Out-of-network care shouldn’t be covered: Out-of-network care shouldn’t be covered under EPO plans, apart from emergency care. If you wish to see a health care provider that shouldn’t be in-network, you’ve got to pay the total medical bill.
  • Can have high out-of-pocket costs: Some EPO plans have high out-of-pocket costs, like a deductible and coinsurance, which might increase the price of coverage. Nevertheless, it is determined by the particular plan and tier you choose.


An HMO plan and an EPO each require you to get medical treatment from an in-network provider. The insurance company won’t cover any medical treatment received out-of-network with either plan.

If you’ve got an HMO, you’re required to work with a primary care provider, and you wish a referral to see a specialist. An EPO means that you can manage your personal care and referrals aren’t required.

When it comes to cost, EPO plans are frequently costlier than HMOs, on condition that they provide barely more flexibility. HMO plans could be a very good option when you’re searching for the bottom cost plan and don’t mind working with a physician to coordinate your care.

EPO vs. HMO differences


A PPO plan offers the best flexibility to see any doctor you would like, whether or not they are in-network or out-of-network.

Your insurance company pays the best amount for in-network care and a smaller percentage for out-of-network care, so PPO members pay more for out-of-network care. In contrast, an EPO plan doesn’t pay for any portion of out-of-network care (except in emergency situations).

Like an EPO plan, PPO plans don’t require you to work with a primary care provider or get a referral to see specialists. But on account of the increased flexibility and better levels of coverage, PPO plans are typically costlier than EPO plans.

EPO vs. PPO differences


Point of service (POS) health plans, which aren’t common, are a hybrid between a PPO and HMO plan.

With a POS plan, you should work with a primary care provider who oversees your medical care, and usually, referrals are required to see a specialist (like an HMO). But POS plans mean you can get treatment from an out-of-network provider and have a portion of the price covered (like a PPO).

In comparison with an EPO plan, POS plans often have smaller networks with fewer doctors and facilities. Due to this fact, the price of an EPO plan is usually barely costlier than a POS plan, nevertheless it is determined by aspects just like the plan tier and out-of-pocket costs. POS make up a small portion of health plans, so you’ll have trouble finding one.

EPO vs. POS differences

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Who Should Get an EPO medical insurance plan?

An EPO medical insurance plan could be a very good option when you don’t want the effort of getting referrals and wish to administer your personal care without the assistance of a primary care provider. It’s also a very good alternative when you’re searching for a plan with some flexibility but don’t wish to pay the best premium for a PPO plan.

Have in mind that an EPO plan doesn’t provide any coverage for out-of-network care. When you want the liberty to decide on any doctor or hospital you would like or when you currently work with providers that aren’t within the EPO’s network, an EPO plan won’t fit your loved ones’s medical insurance needs.

EPO Health Insurance Incessantly Asked Questions

Does an EPO cover out-of-network care?

No, an EPO health plan doesn’t cover out-of-network care unless you’re getting urgent or emergency medical treatment. When you receive care from a health care provider or facility that shouldn’t be within the EPO’s network, you’re required to pay the bill without help from medical insurance. Unlike a PPO plan, EPO plans wouldn’t have cost-sharing for out-of-network care.

Do you wish a primary care physician if you’ve got an EPO?

If you’ve got an EPO insurance plan, you don’t have to work with a primary care physician. You may have the pliability to administer your personal care and select your personal doctors. Because primary care visits aren’t required, you may also give you the option to expedite your treatment by making an appointment with a specialist instantly.

Do EPOs require a referral to see a specialist?

No, you don’t need a referral to see a specialist if you’ve got an EPO insurance plan. You’ll be able to make appointments and select specialists on your personal while not having to see your primary care provider first. Nevertheless, you should select in-network specialists. The visit won’t be covered otherwise.


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