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What Is EPO Insurance?

Alvin Nelson
March 25, 2021
Alvin Nelson

what is epo insurance?

Finding health insurance takes time to choose among so many different options. What is EPO insurance? How is it different from PPO coverage? The questions are numerous when comparing insurance policies online.

It's common for the sheer range of options to confuse people searching for health insurance for the first time. Comparing the bottom line price of health plans is only one aspect; actually using the insurance to pay for care when you need it is another part entirely.

The risk is that if you misunderstand what an EPO is versus a PPO, you may end up paying more for the same doctor's visit unnecessarily.

But the good news is that EPO health insurance is pretty straightforward once you know the essentials of what distinguishes it from other insurance policies aside from the premiums, co-payments, and deductibles.

What is EPO insurance? A quick definition

“EPO” is a common abbreviation for an exclusive provider organization, facilitating healthcare services and coordinating with the insurance carrier. You'll often hear organizations like EPOs referred to as networks in the insurance industry.

Eventually, as you grow older, you'll have to see various doctors to refer you to specialists for further evaluation if you become chronically ill. Ideally, a provider network like an exclusive provider organization ensures that you'll have a seamless transition when visiting a new facility without needing to pay for the specialist's care out-of-pocket.

But before we go further, let's go over how insurance companies actually pay for your healthcare after a doctor charges them for the services you already received. Doing so will clarify what makes an EPO different.

How do doctors and medical practices charge insurance providers for healthcare services?

It's an all too common misconception that any health insurance will be valid with any medical clinic or private medical practice. But this misnomer simply isn't the case in real life.

When you purchase an insurance policy, it will specify which networks you can use to offset the cost of your care. The caveat is that you always have the option to choose your doctor, but if that particular physician isn't in-network, you'll have to pay for the visit out-of-pocket, unfortunately.

Medical practices, whether it be a dentist's office or a general practitioner's office, work with certain insurance carriers to provide a consistent level of service – and keep the cost of the coverage as low as possible to attract more consumers.

If the doctor of your choice isn't in your health plan's network, it's not the insurance company trying to avoid paying for your coverage. In fact, it's quite the opposite: maintaining a network of different healthcare providers helps lower out-of-pocket costs overall.

The most critical information to know is that healthcare provided in-network will be less expensive than services received out-of-network.

How do health insurance provider networks differ from one another?

Generally, what distinguishes health insurance provider networks from one another are:

  • Primary care physician requirements
  • Out-of-network coverage exclusions
  • Referral requirements for specialists
  • Cost of premiums, deductibles, and out-of-pocket expenses

The most common confusion stems from the fact that a single insurance provider may offer all types of health insurance; others may not provide as many options, limiting your choices at the end of the day.

Primary care physician requirements

Specific networks like a health maintenance organization (HMO) require that you choose a primary care physician (PCP) within their particular network. An EPO, depending on the insurance company, may require an in-network primary care physician, but that's not always the case.

The general rule of thumb is that if a network's policy specifies that you must see a PCP, it will also require a referral to see a specialist.

Referral requirements for specialists

Along those lines, most EPOs don't require a referral from a PCP. That's one of the main benefits of paying for an EPO that may be more pricey than you expect. There won't be any need to file claims with multiple medical practices when all of your healthcare is in-network, including referrals to specialists.

Out-of-network coverage exclusions

Receiving medical services out-of-network arguably leads to the most issues. Most insurance companies will operate on a case-by-case basis when specific situations arise, such as joining an EPO in the middle of a difficult course of treatment (i.e., chemotherapy).

An EPO will only pay for out-of-network healthcare if you go to the emergency room. This stipulation is actually relatively new, included in the Affordable Care Act. But the catch is that if you need to have an extended hospital visit, you may need to transfer to an in-network facility to avoid paying out-of-pocket.

Cost of premiums, deductibles, and out-of-pocket expenses

Although it's never easy to generalize the price of health insurance, the cost of premiums, deductibles, and out-of-pocket expenses is another factor that distinguishes an EPO from a PPO.

While there are always exceptions, an EPO usually comes with a lower premium than PPO health plans, but the deductibles will be higher. But of all types of health insurance, an EPO is the most friendly when it comes to out-of-pocket costs.

EPO vs. PPO – Which insurance works best for you?

A PPO health plan doesn't require a referral to see a specialist, and – unlike the majority of EPOs – it will allow for out-of-network doctor's visits. The difference is that a PPO will charge you more for receiving care out-of-network. That's why a PPO has more flexibility than an EPO.

But when it comes to comparing EPO vs. PPO, the most significant advantage of an EPO is that they have a much more extensive network of healthcare providers. Neither type will likely come with fixed co-pays too.

With so many factors to take into account, it's challenging to make the best decisions without a way to compare health insurance policies from multiple carriers in one place.

How to compare EPO insurance versus another type of health coverage

When you need an accessible yet comprehensive tool to shop for health insurance online, whether or not the plan is an EPO, HealthPlans.com is ready to use.

It's an effective way to compare different types of health insurance side-by-side without any unnecessary, confusing legal jargon getting in the way.

All it takes is a short questionnaire and your basic contact information to begin seeing quotes from several different insurers at one time.

The best insurance plan for your needs may not suffice for others but be just right for your budget.

HealthPlans.com is available in all 50 states to ensure that consumers can always obtain the best rates.

Visit the HealthPlans.com homepage begin shopping for EPO health insurance today!

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Advertised Pricing:

There are several factors that impact your monthly premium; including, but not limited to your age, geographical location, annual income, dependents, and the type of plan you choose. Monthly premiums do not include out-of-pocket costs.

The advertised price may not be typical. It was generated using the Kaiser Family Foundation's subsidy calculator that was accessed on September 16, 2020. The following parameters were used: 21 year old adult, non-tobacco user, annual income of $24,700 in 2020, no children, and no available coverage through a spouse's employer. The resulting monthly premium was $30 per month (or $360 per year after $2,751 in subsidies) for a Bronze Plan. Even when using the same parameters, this result is subject to change.