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. Generally, 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. (No referrals needed for non-gated plans only.)
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, most EPO insurance plans offer the freedom to see any network provider without a referral and typically do not make you choose a primary care provider (PCP). (This applies to non-gated plans only.) 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 is the difference between a gated EPO plan and a non-gated EPO plan?
It’s important to know that if you have a “gated” EPO plan, you will typically need a referral from a PCP to see a specialist. If you have a “non-gated” EPO plan, generally, you will not need a referral to see specialists, if the provider is in the network for your plan. Be sure to check the specifics of your plan's benefits to learn whether referrals are needed before you see a specialist.
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 (This refers to non-gated plans only. Check your plan benefits to see if your plan is gated or non-gated.)
- 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
| EPO | PPO | |
|---|---|---|
| Do I need referrals? | No (if you have a non-gated plan) | 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?
Typically, 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. However, with gated EPO plans, you may need to get referrals from your PCP. Check your specific plan benefits to see if you need a referral before you see a specialist.
What’s a dental EPO plan?
EPO dental plans work just like EPO health plans. Generally, you can see any dental provider in your EPO network without a referral. But check your plan details to be sure. 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 one 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.