An Exclusive Provider Organization (EPO) plan is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Similarly to HMO plans, EPO plans cover services rendered by providers that are in-network (for a certain geographic area) ONLY. Out-of-network care is not covered except during an emergency. Unlike HMO plans, you are not required to have a Primary Care Physician (PCP), nor are you required to have a referral in order to visit a specialist. However, any specialist you visit MUST be in-network.
With an EPO plan, you can expect to pay a lower monthly premium than you would for a PPO plan. Additionally, because you are required to stay in network for services your deductible and other out-of-pocket expenses can be kept low. Similarly to some HMO plans, you may not owe anything for care received during a hospital stay once you’ve met your deductible.
The Open Enrollment Period for 2019 coverage may still be open in your area. Click here to explore your options.
A lower monthly premium doesn’t mean a higher deductible.
You don’t have to visit a PCP before you can see a specialist, and YOU get to choose your specialist, provided they’re in-network.
Your service provider works with the insurance company directly, so you don’t have to file any claims.
Coverage will only be provided for services received by in-network providers. So, you may owe much more (if not full cost) for out-of-network services, unless it’s a medical emergency.
EPO providers are split by geographic area. You may not have access to healthcare that best suit your needs if your area doesn’t have many in-network providers.
Although a referral is NOT required from a PCP in order to see a specialist, the specialist must also be in-network. This can limit your options when it comes to who provides your care.
There are several other healthcare plans available to meet your needs. Check out the links below for more information.
Great choice for people who want to keep their premiums low, especially if you’re happy to see your PCP first when you need more specialized care.Learn more »
Perfect for people who prioritize choice and flexibility. Premiums are higher than other plan types but you’ll have coverage for more care providers.Learn more »
POS plans are similar to HMO plans but offer the increased flexibility of providing coverage for care costs outside of the network.Learn more »