EPO Health Insurance Plan: A Complete Guideline

EPO Health Insurance Plan: A Complete Guideline
EPO Health Insurance Plan

You could be wondering if an EPO health insurance plan is the best option for you when searching for a new health insurance coverage. EPOs are typically a sensible decision for many people because of their affordable rates and low cost.

What is EPO health insurance?

Exclusive provider organizations, or EPOs, are a kind of healthcare management insurance plan where services are only reimbursed if you visit doctors, specialists, or hospitals in the network of the plan (except in an emergency).

Because the EPO will only pay for medical expenses if they are paid for by healthcare organizations with which the EPO has a contract, this classification is given to EPO health insurance. Similar to other health insurance plans that have a monthly payment, EPOs will cover out-of-area care in an emergency to keep you inside their managed care organizations.

Similar to their relatives, the PPOs & HMOs, EPO health plans have cost-containment requirements for how you must receive your medical care.

How does the EPO health insurance plan work?

In an EPO health insurance plan, you are only covered for the medical care you receive from local providers, with the exception of emergencies or times when you have prior authorization from your insurance provider. Below, find the health insurance terms you'll need to understand the fundamentals of EPO health insurance:

  • Network coverage: To give plan members the best treatment possible, EPO health insurance plans engage with hospitals and physicians. Network providers or "in-network providers" are the terms used to describe these licensed facilities and caregivers. But, regardless of whom you see or where you go for assistance, these plans cover emergency services.
  • A primary care physician: Often known as a family doctor or PCP, is a general practitioner who manages your regular medical needs. EPO plans do not mandate that participants have an assigned, in-network PCP.
  • Copay: You must pay a copay when you sign up for an EPO network. For instance, this might be $20 for a doctor's appointment or $100 for a trip to the emergency hospital.
  • Deductible: EPO health insurance often has a deductible, just like other insurance plans. This is the amount you contribute toward covering the cost of your medical care. For instance, if your deductible is $500, you will be responsible for the first $500 of your medical expenses in a given year. Higher deductibles typically translate into reduced monthly premiums.
  • Coinsurance: Plans that divide the expense of healthcare among participants and insurance providers. In the case of an 80/20 coinsurance arrangement, for instance, your EPO health insurance would cover 80% of the cost of care while you would be responsible for the other 20%.

Who needs a healthcare EPO plan?

An EPO health insurance plan might be a good option if you don't want to deal with getting referrals and would rather manage your own care without a primary care physician's help.

Making this choice is also wise if you want a plan with some flexibility but don't want to pay the highest PPO premium.

Don't forget that an EPO plan does not cover services obtained outside of the network.

If you prefer to choose any doctor or facility you choose or if you already deal with providers who aren't in the EPO's provider pool, an EPO plan might not be able to provide your family with the healthcare coverage they need.

How does EPO health insurance plan differ from other types of health insurance?

EPO health insurance is different from other managed care plans in terms of provider options, cost, and flexibility. Their major differences are as follows:

  • EPO vs HMO insurance

Similar to HMO plans, EPOs require the use of network providers for regular care. The primary distinction is that an HMO requires you to select a PCP who will oversee your medical treatment and make referrals for specialist visits. You can visit specialists without a referral if you have an EPO. But you should first confirm that the supplier is a part of your EPO network and see if your plan calls for prior authorization.

  • EPO vs PPO insurance

An EPO doesn't need specialty referrals, much like a PPO. Yet unlike an EPO, which only covers in-network treatment unless there is an emergency, a PPO typically offers some coverage for out-of-network services. Both EPOs and PPOs typically have a deductible, which is the sum you are responsible for paying out of pocket before coverage starts in.

  • EPO vs POS insurance

POS health plans permit both in-network and out-of-network care, albeit out-of-network services will cost more. To oversee their care and make expert referrals, POS members must select a PCP. With an EPO, you are limited to in-network care but are not required to choose a PCP or get recommendations. A deductible is often not required for POS policies.

How much does an EPO plan cost?

Depending on where you reside and the particular plan you select, you may have to pay different amounts for your EPO health insurance premiums and copays. You will often be paying for copays, deductibles, and coinsurance.

If you need help paying your monthly premiums, a health insurance subsidy is an option.

An EPO health insurance plan costs an average of $436 a month for a 30-year-old.

Benefits and drawbacks of EPO health insurance


  • You are not required to go to a primary care doctor
  • Specialist visits are possible without a referral
  • EPOs frequently have lower premiums than HMOs due to their higher deductible
  • They generally have lower monthly premiums than PPO policies, but greater deductibles
  • Broad network


  • Unless in circumstances of emergency or prior authorization, care received outside the network of your insurance plan is not covered
  • EPO programs often give fewer options to doctors
  • You must continue to use the plan's network of providers if you don't want to pay the full cost of your treatment

How do you purchase an EPO plan?

Only if your employer offers it or if you have group health insurance through your job are you eligible to choose an EPO Medicaid plan. 

If your employer doesn't offer coverage, you can acquire an EPO through the ACA's new insurance marketplace.

You can only select a new plan during Open Enrollment, which takes place from November through December and lets anyone buy an insurance policy.

If you change jobs or have a major life change, such as the birth of a child, you can qualify for Special Enrollment, which enables you to enroll in a new plan outside of the Open Enrollment period.

Final word

If you want to manage your own care without the help of a primary care provider and don't want the trouble of receiving referrals, an EPO health insurance plan may be a smart choice. It's also a smart decision if you want a plan with some flexibility but don't want to pay the highest PPO cost.