EPO Insurance

An EPO (Exclusive Provider Organization) insurance plan is a network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. Basically, an EPO is a much smaller PPO. EPO insurance plans offer a very limited number of providers who offer large discounts on their rates.

Types of EPO Insurance plans

The current industry standard requires that a patient select a Primary Care Physician and when needed obtain authorization from that Primary Care Physician to receive specialty services. Some patients may not have to choose a Primary Care Physician and only have to choose a medical group. A patient must stay within the contract network and only use preferred providers. There typically is a lifetime policy maximum with this type of plan. If a patient goes out of network they may be responsible for the entire balance that is not paid by the payer associated with the services provided.

The other type of EPO insurance plan is one where the benefits are those of a PPO insurance plan but the provider panel from which members obtain care is smaller than a PPO insurance plan panel.

EPO vs. PPO

People who have PPOs have more flexibility to choose a primary care doctor of their own choice. A person with a PPO will also be able to go to a specialist without first having to get an authorization from their primary care physician. EPO members do not receive any reimbursement or benefit if they choose to visit medical care providers outside of the designated doctors and hospitals within the established network. Some EPO insurance plans will give partial reimbursement outside of the network in emergency cases. Things to think about before joining an EPO

  • Does the organization provide what you think you will need in the future?
  • Do you have any special needs?
  • If you have your own provider or specialists, do they belong to the network or must you switch to the EPO network?
  • Is the EPO reliable?
  • Does the EPO have a history of quality care in your area?
  • Are the charges reasonable, or would you be better served by an insurance plan, especially if the plan is partially paid for by your employer?