Your Complete Guide to EPO Insurance

EPO (exclusive provider organization) insurance is a health plan that limits insurance coverage to doctors, specialists and medical facilities within the plan’s network. While EPO insurance is generally more expensive than an HMO plan, EPOs typically feature a more robust provider network and do not require you have a primary care physician or referral before seeing a specialist.

Keep reading to see how EPO insurance stacks up against other types of health insurance and whether an EPO is right for you.

How Does EPO Health Insurance Work?

An EPO is a type of health insurance plan that limits covered healthcare coverage to doctors, specialists and hospitals within your plan’s approved network. Below, are key concepts for health insurance and how they work with an EPO:

Network Coverage

If you want your health insurance company to cover your medical services, you must receive care from in-network doctors, specialists, urgent care facilities, hospitals and labs that are contracted with your EPO.

If you see a healthcare provider outside the EPO network, you will have to pay out of pocket for that service.

Emergency care is one exception — these expenses are typically covered even if an out-of-network provider administers emergency treatment on you.

Primary Care Physician

A primary care physician (PCP) — your regular healthcare provider that usually specializes in general medicine — is not required with an EPO. However, those with EPO plans should still consider a PCP, since this professional will usually be your first and main point of contact for your general health concerns. Over time, your PCP will know your health history and can explain additional services, such as:

  • Urgent care
  • Telemedicine
  • Retail clinics
  • Lab services
  • Outpatient surgery

Premium

The premium for an EPO is traditionally more than an HMO but less than a PPO (preferred provider organization) or POS (point of service) plan. The premium is the set amount of money customers pay for insurance coverage. Payments are due every month.

Copay

The copay is the money you spend on a covered medical service and will vary depending on the service you’re getting. Copayments are your portion of the cost of healthcare services. Your insurance company pays the rest.

Deductible

Your deductible is the amount you pay for a covered medical expense before your insurance begins to kick in. You will have the option to choose how high or low of a deductible you want. The lower your deductible, the higher the premium and vice versa.

Coinsurance

Coinsurance is the percentage you pay for covered healthcare expenses while your health insurance will pay for the remaining amount. A common example is 20/80 wherein you will pay 20% for healthcare expenses and your health insurance pays the remaining 80%. How much you pay will usually be based on a discounted rate that is negotiated by doctors and hospitals and insurance companies.

How Much Do EPO Health Insurance Plans Cost?

The cost of EPO insurance will vary  vary due to several factors such as:

  • Age
  • Deductible
  • Health history
  • Health plan
  • State

The table below shows the price differences between several EPO insurance plans.

 

EPO Bronze Basic

EPO Bronze Reserve With an HSA

EPO Catastrophic

Deductible

$9,100

$7,450

$9,100

Primary care physician visit

Visits 1-3: $20 no deductible

Visits 4+: 0% after deductible

0% after deductible

Visits 1-3: $50, no deductible

Visits 4+: 0% after deductible

Specialist visit

0% after deductible

0% after deductible

0% after deductible

Inpatient hospital

0% after deductible

0% after deductible

0% after deductible

Generic prescription drugs

$25 no deductible (integrated with medical deductible)

0% after deductible (integrated with medical deductible)

0% after deductible (integrated with medical deductible)

Source: Independence Blue Cross

EPO insurance is sold in five tiers: bronze, silver, gold, platinum and catastrophic. The amount you pay for coverage will depend on which tier you choose. These tiers do not measure the quality of care offered.

Bronze

Bronze-tier health plans will have the lowest monthly payments and higher out-of-pocket costs. Those who want healthcare coverage for worst-case scenarios and don’t anticipate using their health insurance too often may find the lower monthly payments appealing.

Silver

A silver plan has moderate monthly payments and out-of-pocket costs. If you qualify for a cost-sharing reduction, purchasing a silver plan could save you hundreds or thousands every year if you regularly visit your doctor. Those who can afford higher payments and tend to utilize medical care more often find silver plans to be ideal.

Gold

Gold plans will have higher monthly payments and lower out-of-pocket costs. If you’re someone who uses their healthcare coverage frequently and doesn’t mind paying more per month, then a gold plan is a good option for you.

Platinum

The platinum tier charges some of the highest monthly premiums but your out-of-pocket costs are even lower than a gold plan. A platinum plan may be more cost-effective if you or a family member has chronic health issues that require regular medical attention since virtually all of your medical costs will be covered.

Catastrophic

A catastrophic plan will have low monthly payments and high deductibles and can protect you from serious illness and injury. Catastrophic insurance is primarily for those under 30 but older people may still qualify if they have a hardship exemption or affordability exemption. The affordability exemption applies if the lowest-priced coverage available to you would cost more than 8.09% of your household income. Qualifying events for the hardship exemption include:

  • Homelessness
  • Shut-off notice from a utility company
  • Death of a family member
  • Medical-related debt
  • Property damaged by a fire, flood, or another natural or human-caused disaster
  • Eviction, facing eviction or foreclosure
  • Domestic violence
  • Bankruptcy
  • Your state didn’t expand eligibility for Medicaid under the Affordable Care Act
  • You had another hardship

You may also qualify for a hardship exemption if your expenses increased due to caring for an ill, disabled or aging family member. If another person is court-ordered to provide medical support to a dependent who is denied Medicaid or CHIP, you may still qualify for a hardship exemption.

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What are the Pros and Cons of an EPO Insurance Plan?

An EPO comes with benefits and drawbacks. The below table breaks down the pros and cons of an EPO plan.

Pros

Cons

You’re not required to use a primary care physician

Healthcare must come from within your plan’s network if you don’t want to pay the full cost of treatment

Referrals aren’t required to see specialists

You will not receive coverage outside of your plan’s network unless it’s an emergency

EPOs usually have lower premiums than PPOs and POS’

EPOs usually have higher premiums than HMOs

What's the Difference Between EPO, HMO, PPO and POS?

An EPO is one of several coverage options available by health insurance companies. Each coverage type dictates how coverage works with in- and out-of network providers, if you need a PCP or a referral for a specialist. Below, we compare EPOs to HMOs, PPOs and POS’ (point of service).

 

HMO

PPO

EPO

POS

Primary Care Physician Required?

Yes

No

No

Yes

Referral Required for Specialists?

Yes

No

No

Yes

Out-of-Network Coverage?

No

Yes

No

Yes

Network Size

Lowest

Highest

Lower

Higher

Cost

Lowest cost

Highest cost

Lower cost

Higher Cost

EPO vs. HMO

EPOs and HMOs both require members to seek healthcare within their provider network. Out-of-network treatment must be paid out of pocket (except for emergency treatments).

Unlike an EPO, those with HMO plans are required to have a primary care physician. Referrals are required before you can see a specialist, as well. EPOs lack this requirement, which offers some layer of convenience and freedom to their policyholders.

EPOs generally cost more than HMOs due to their larger network size.

EPO vs. PPO

PPOs offer greater flexibility with seeing an in- or out-of-network provider. PPO allows policyholders to seek medical services outside the network — you will still bear some out-of-pocket costs but your insurer will provide some coverage. In contrast, an EPO will not provide health insurance coverage for out-of-network care unless it is an emergency. This added flexibility helps explain why PPOs typically cost more than EPOs.

Neither EPOs nor PPOs requires policyholders to obtain a referral before they can see a specialist. You are also not required to have a PCP.

EPO vs. POS

A POS plan allows policyholders to seek treatment out-of-network at a higher cost while an EPO plan won’t cover out-of-network care. While an EPO doesn’t require you to get a referral before seeing a specialist, this requirement will apply to a POS plan.

Who are EPO Health Insurance Plans Best For?

EPO insurance plans are a great option for people who don’t want to have a primary care physician or who don’t want to undergo the sometimes tedious process of getting a referral for a specialist.

In terms of cost, EPOs make a great mid-ground plan — typically costing more than HMOs but less than a PPO or a POS.

EPO plans typically have a larger network than HMOs, potentially granting members access to a wide selection of general providers and specialists.

FAQs

Does EPO insurance require referrals for specialists?

EPO insurance allows policyholders to see an in-network specialist without requiring a referral from their primary care physician.

Do EPO health insurance plans cover out-of-network care?

EPO health insurance plans do not provide coverage for out-of-network care unless it is an emergency. Outside of emergency care, you will pay out of pocket for seeing an out-of-network provider.

Does EPO insurance cover hospital visits?

EPO insurance will cover the cost of hospital visits after applicable copays or deductibles as long as the hospital is inside the EPO’s network.

What does EPO mean in health insurance?

EPO stands for “exclusive provider organization.” Those with an EPO will have coverage for doctors, specialists and hospitals within the EPO’s network.

Is an EPO better than an HMO?

While EPOs typically carry larger provider networks and don’t require a primary care physician, an HMO is usually more affordable. The best option will depend on your medical needs and budget.

Key Takeaways

  • EPO stands for “exclusive provider organization” and is a type of healthcare plan that covers services received by in-network healthcare providers.
  • EPOs do not require you to have a primary care physician or obtain a referral before seeing an in-network specialist.
  • EPO plan costs will vary by age, deductible, health history and location, among other factors.
  • An EPO will usually have a larger coverage network than an HMO.

SmartFinancial can help you find the plan you need for the price you want. Enter your zip code below or call 855.214.2291 to receive your free health insurance quotes.

Sources

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