Learn about Exclusive Provider Organization (EPO) plans
An EPO is a type of health plan that falls somewhere between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) in terms of cost and flexibility. With an EPO, members have only in-network coverage (except for emergencies), but they do not need to select a primary care physician (PCP) or get referrals to see specialists.
How does EPO health insurance work?
Here are the fundamentals of an EPO plan.
Network coverage. EPO plans contract with doctors and hospitals to provide care to the health plan’s members. These providers are called “network providers” or “in-network providers,” and they include physicians, specialists, and facilities, like labs, hospitals, and urgent care centers. A provider that does not have a contract with the health plan is called an “out-of-network provider.”
- EPO members are only covered for services received from in-network providers. So, it’s important for EPO members to know which providers are in their network.
- EPO members are covered for emergency care no matter where they are — in or out of network.
Primary Care Physician. A PCP, or family physician, is a general practitioner who provides routine, everyday health care.
While EPO plan members aren’t required to use a PCP to coordinate their care, a PCP can help them manage their long-term health and save them time and money by helping them understand their options for certain services, including:
- Retail clinics, urgent care centers, and telemedicine visits (if available to you)
- Blood work and other laboratory services
- Outpatient surgery
Costs. In addition to a monthly premium, EPO members may have out-of-pocket costs when they receive care.
- Copay: A copay is the set amount a member pays for a covered health care service. For example, the copay to see a doctor could be $20, while the copay for an emergency room visit could be $100.
- Deductible: This is the amount a member pays each year before the health plan starts to share the costs. For example, if the health plan has a $1,000 deductible, the member pays the first $1,000 of the costs for the services received. Once the deductible has been met, the insurance will pay for some or all health care services, depending on the health plan.
- Coinsurance: This is the percentage you pay for some covered services. If your coinsurance is 20 percent, your health insurance company will pay 80 percent of the cost of covered services, and you will pay the remaining 20 percent. The amount you pay is typically not based on the full retail price of the service. It is based on a discounted rate negotiated by your insurance company with heath care providers like doctors and hospitals.