What is an EPO?
EPO stands for Exclusive Provider Organization. An EPO is a kind of managed care plan.
Networks: Similar to an HMO, you must see providers within the EPO's network. Each EPO has a network of doctors, medical groups, labs, hospitals, and other providers. The EPO usually won't pay for care you get from a doctor or hospital that isn't in the network, unless it's an emergency.
Check with your EPO about its network of providers. Ask the EPO for a copy of its provider directory. Or look on the plan’s website.
Primary care doctor and medical groups: In most EPOs, you are not required to select a main doctor, called a primary care physician or PCP.
The doctors in an EPO's network that you see may be a part of a medical group. A medical group is a group of doctors and other providers that contract with a health plan.
Check with your EPO about its rules and network of providers.
Referrals and pre-approvals: Similar to a PPO, you can usually see any doctor within an EPO's network without a referral from your main doctor.
You or your doctor will likely have to get pre-approval from your EPO before you can get certain kinds of medical procedures, tests, or treatments. You also must get approval from your EPO to get care from a provider outside the network, unless it’s an emergency.
Check with your EPO about its rules for referrals and pre-approvals.
Why would I choose an EPO?
- You might save on costs. EPOs often have smaller provider networks and other plan features that are designed to keep your costs affordable. Be sure to compare all costs (not just the premium) related to the care you need and providers you prefer seeing.
- You want to be able to see specialists and other providers without a referral from your main doctor.
Why would I NOT choose an EPO?
- You prefer to go to a certain doctor or hospital that is not in the EPO's network.
- You want more choices in providers from a larger network.
- You want the flexibility to see providers who are not in the network, even if you have to pay more.