What is an EPO health plan?

During your search for health insurance, you may have come across EPO plans. An EPO plan is a common type of health insurance that requires you to get care from a certain network of providers. EPO insurance covers out-of-network care only in emergencies or special circumstances (like during complex treatment or if the EPO network doesn’t have the type of provider you need).

You’ll likely have a higher deductible and lower monthly payments with EPO insurance compared to other types of health plans. EPO health insurance may be a good fit for someone who enjoys the freedom of choosing their providers without referrals, while being comfortable staying within the EPO network.

What does EPO stand for?

EPO, meaning “exclusive provider organization,” refers to the rule of staying within the plan’s network of select providers. If you get care outside the EPO network, you’ll likely have to pay the full cost of that visit.

How does an EPO work?

Think of EPOs as a combination of health maintenance organization (HMO) and preferred provider organization (PPO) plans. Like a PPO, EPO insurance offers the freedom to see any network provider without a referral and typically doesn’t make you choose a primary care provider (PCP). Without a PCP to send referrals on your behalf, you may have to get preapproval for certain services.

Similar to HMOs, EPO plans don’t offer coverage for out-of-network care. It’s important to know which doctors, hospitals and labs are in your EPO plan’s network so you don’t get a bill with surprise costs.

What’s the advantage of an EPO plan?

EPO health insurance offers some benefits like those you’d get from a PPO and HMO health plan, like flexibility and lower costs. Advantages of an EPO plan include:

  • No referrals needed
  • Usually no requirement to choose a primary care provider
  • Generally lower out-of-pocket costs than a PPO plan

What’s the difference between an EPO and a PPO?

One major difference between EPO and PPO insurance is that unlike PPO’s, EPO plans don’t offer coverage for out-of-network care. Because of that network limitation, EPO plans usually come with lower out-of-pocket costs than PPO plans. Be sure to compare and understand the differences between EPO and PPO plans before deciding which to buy.

EPO vs. PPO plans

Do I need referrals? No No
Is there coverage for out-of-network care? No Yes
Am I required to choose a primary care provider? Not usually No

Do I need a referral with an EPO?

EPO insurance gives you the freedom to see any network provider without a referral. This can make getting the care you need simple and convenient.

What’s a dental EPO plan?

EPO dental plans work just like EPO health plans. You can see any dental provider in your EPO network without a referral. Getting dental care outside your plan’s network will cost you more (possibly the whole bill).

EPO plans are one of many health insurance plans

Remember, there are lots of options on the market. EPO plans are just 1 type of health insurance you may be interested in. Take the time to research different plans in your area so you can pick your plan with confidence.