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What Is an Exclusive Provider Organization Plan?

By Deborah Gordon

Deborah Gordon

Deborah Gordon is author of The Health Care Consumer’s Manifesto: How to Get the Most for Your Money (Praeger 2020). Her research and commentaries have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, TheHill, Kiplinger, and Managed Care Magazine.

Updated on July 1st, 2021

Reviewed by Diane Omdahl

Diane Omdahl Expert Reviewer

Diane Omdahl has been helping people navigate the complexities of Medicare for more than three decades. She is a nationally recognized Medicare expert, a registered nurse, serial entrepreneur, and has served as a technical expert for the Centers for Medicare and Medicaid Services (the organization that runs the Medicare program). She is a frequent speaker on Medicare-related issues. She has been featured in many national publications, including the Washington Post, CBS MoneyWatch, Forbes, The Wall Street Journal Market Watch, Kiplinger, and many more. Her most recent startup, 65 Incorporated, helps people 65 and older get the clear, correct, complete, and credible information they need to make important Medicare decisions. She is also the architect behind the i65 Medicare optimization software suite. i65 enables financial advisors to help clients make smart Medicare decisions.

In this Article

How It Works Benefits and Drawbacks EPO Plan vs Other Plans How Much It Costs Right for You? Next Steps

We want to help you make educated healthcare decisions. While this post may have links to lead generation forms, this won’t influence our writing. We adhere to strict editorial standards to provide the most accurate and unbiased information.

An exclusive provider organization (EPO) plan is a type of health insurance plan that requires members to use a set network of doctors, hospitals, and other healthcare providers except in an emergency. EPO plans typically only cover services offered by in-network providers. EPO plans may have lower costs than other types of healthcare plans if you can stay in-network.

What You Need to Know 

Exclusive provider organization (EPO) plans limit members to using a network of doctors and other providers.

EPOs typically cost less than preferred provider organization (PPO) plans.

EPOs rarely have out-of-network benefits, which means you’d have to pay out-of-pocket for care from out-of-network providers.

How Does an Exclusive Provider Organization Plan Work?

Health insurers negotiate payment terms with doctors and facilities to create a network of participating providers. When health plan members get services from those providers, the providers bill the insurer per service according to their agreed-upon fees. 

You generally don’t need to pick a primary care physician (PCP) or get referrals to see specialists.

If you have an EPO plan, your insurer won’t cover services from out-of-network providers unless you’re in an emergency situation. 

You might need to get prior authorization, also called pre-authorization or prior approval, for your insurer to cover certain services. This is one way health insurance companies control their costs. If your EPO plan doesn’t authorize the care, your insurer won’t pay for it. So you may consider going without the care or paying out of pocket. The specific services that require pre-authorization vary by plan, but typically include hospitalizations, imaging (MRIs or CT scans), and expensive medications. Emergency care doesn’t require pre-authorization. 

Generally, your doctor will ask your insurer for prior approval. But getting pre-authorization may be your responsibility. Check your plan to be sure. 

What Are the Benefits of an Exclusive Provider Organization Plan?

You have flexibility in which providers you see, as long as they’re in-network. You likely won’t have to deal with picking a PCP or getting a PCP’s referral before you see a specialist. You also won’t have to file claims, since your provider will bill your insurer directly at the agreed-upon rate.

Additionally, EPO insurance plans often have lower costs than other health insurance plans.

No Referrals

EPO policies don’t require referrals, so you can see any in-network specialist without the paperwork.

What Are the Drawbacks of an Exclusive Provider Organization Plan?

EPO plans require members to get their healthcare services only from in-network doctors, hospitals, and other providers. This could mean you have to stop seeing a favorite doctor if they don’t accept your plan. You’re also responsible for making sure your providers are in-network before you go. 

How Does an EPO Plan Differ From an HMO Plan?

EPO and health maintenance organization (HMO) plans both require you to stay in-network and may not cover out-of-network care. Most HMOs, though, require members to choose a PCP and to get referrals from the PCP to see specialists. There are EPO plans that require a PCP, but they don’t require referrals. 

How Does an EPO Plan Differ From a PPO Plan?

Unlike EPO plans, preferred provider organization (PPO) plans cover services from in- and out-of-network providers. In exchange for that flexibility, PPOs tend to have higher premiums and out-of-pocket costs than EPO plans. Both plan types allow members to see specialists without a referral. 

How Does an EPO Plan Differ From a POS Plan?

Point of Service (POS) plans combine features of both HMO and PPO plans. Unlike EPO plans, POS plans may cover services from in- and out-of-network providers and require referrals to see specialists. POS plans are more flexible but may have higher premiums.

How Much Does an Exclusive Provider Organization Plan Cost?

Health insurance policy costs vary by carrier, geography, and specific plan. In general, EPOs typically have lower premiums and lower out-of-pocket costs — such as copayments, coinsurance, or deductibles — than PPO plans. Check any plan you’re considering for specific details on costs. 

When Can You Go Out-of-Network with an Exclusive Provider Organization Plan?

Health insurance plans, including EPOs, must cover emergency care at the same level they would pay for in-network care or at rates they find “reasonable and customary.” The hospital or emergency facility may be allowed to send you a bill for whatever your health plan doesn’t pay, but many states protect consumers from such bills in true emergencies. If you have a medical or mental health emergency, your EPO is required to cover it. 

Emergencies Always Covered

Emergency care is covered whether it’s in-network or not.

How Common Are Exclusive Provider Organization Plans?

Among employers that offered at least one HMO or EPO plan in 2019, 13% offered EPO plans and 4% offered both HMO and EPO plans. Companies with 5,000 or more employees are more likely to offer EPO plans. Of those companies, 22% offered EPO plans and 11% offered both HMO and EPO policies.1 

If you want to visit medical providers without worrying about whether they’re in-network, an EPO policy may not be the best choice. But if you don’t mind a more limited provider network in exchange for lower health insurance costs, and you don’t want to get referrals to see specialists, an EPO plan could work for you. 

Next Steps

If an EPO health insurance policy sounds like the right choice for you, research the available plans in your area. Make sure any doctors or facilities you want to use would be in your provider network. Check the premium, deductible, and other costs to see if the plan fits into your budget. You want to know that the plan meets your needs before you sign up.

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  1. Kaiser Family Foundation. “2019 Employer Health Benefits Survey.” kff.org (accessed March 10, 2021).