What is an EPO?

When shopping for health insurance in Texas, you will find companies with an insurance plan network; sometimes, they offer you multiple options. While these networks all adhere to Affordability Care Act standards, they are not all alike. Network options, like an Exclusive Provider Organization (EPO), have guidelines that subscribers need to follow, or they place their coverage at risk. However, for some, this may be the best coverage option due to the benefits the network provides. Let’s review the pros and cons of an EPO and let you decide for yourself.

Before we begin, we would like to review the different parts of insurance. Then we will explain how an Exclusive Provider Organization works to provide health insurance to you and your family.


What are the Parts of Health Insurance in Texas?

Insurance plans have several pieces that work together to provide you with coverage. Let’s define each of the most familiar terms.

DeductibleA deductible is the amount you pay out-of-pocket before your coinsurance starts to pay its portion. It is based on a calendar year and refreshes each year. Deductibles are one of the factors that determine your monthly premium. Generally, the lower your deductible, the higher your premium. If you increase your deductible, you can see a lower rate.

CopayCopays are fees you pay when you visit a medical provider. It’s important to understand this fee is for your visit alone, not the treatment you receive. It can be a flat dollar amount or a percentage, varying by treatment, medical event, and plan. Some medical events, like a well check-up or other preventive service, can be included in your visit and would not carry a charge. See your medical plan for details.

Out-of-Pocket MaxYour Out-of-pocket max is the most you will pay per individual for your medical expenses. Once you meet your deductible, pay up to the amount stipulated on coinsurance, and reach your out-of-pocket maximum, your policy begins to pay all of your medical expenses for that individual. Each person on your policy has an out-of-pocket max. You can read more about them through the highlighted link above.

Primary Care Physician:A Primary Care Physician (PCP) is a doctor you see for general care. With some medical plans, you must select a PCP when you sign up and see this doctor before seeing a Specialist or having other tests done. You may also need to remain within a network of physicians in order to have coverage.

Health Insurance Plan Network –A plan, or provider, network is a list of health care providers that a health insurance contracts with. There are three primary health plan networks, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Exclusive Provider Organizations (EPOs). Each has different ways they handle benefits, and each varies in how much they cost.

Now let’s explain health insurance plan networks and how EPOs work.

What are Health Insurance Plan Networks?

When shopping for an individual or family health insurance policy, you may begin with shopping for insurance by name. You may hear of health insurance companies like Blue Cross Blue Shield of Texas or UnitedHealthcare Insurance. But how do each of these health insurance companies work?

First, when you enroll with a health insurance company in Texas, you will begin with selecting a health insurance plan network. As we defined earlier, there are three primary types: HMOs, PPOs, and EPOs. Blue Cross Blue Shield of Texas is an HMO. OscarInsurance is an EPO, and Aetna offers all three, including PPOs.

Your network type determines the coverage you will receive. It may:

  • Outline which doctors you are able to visit.
  • Outline which facilities you can use.
  • Require you to request permission to go out of network.

All health insurance providers in Texas have a list of providers they are contracted with. Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs) require you to choose your doctor, or risk not having coverage. Preferred Provider Organizations (PPOs), you are not bound by that rule, and you have a larger network of physicians and facilities from which to select.

What is an EPO Network?

An Exclusive Provider Organization (EPO) Network is a type of health provider network. It is one of the more restrictive networks. However, it does have certain freedoms that other networks do not provide. Let’s review what you receive with an EPO.

Can I see any Primary Care Physician with an EPO?

With an Exclusive Provider Organization (EPO), you do not have to designate a Primary Care Physician. However, you are required to use only the doctors, hospitals, and medical facilities within your network. If you use a provider outside of your network, you will not have coverage and will have to pay out of pocket. This rule does not apply if you are in an emergency situation.  

Do I need a doctor’s referral for advanced medical care?

You do not need a referral to seek treatment from a specialist or have tests done. And while you don’t need a referral, you need to ensure they are within your network. You may also need authorization for advanced medical care. Contact your insurance provider for further information.

Do I have to pay more for an EPO plan?

For the most part, premiums for EPOs will be more than an HMO but less than PPOs. The reason for this is the freedom the plan gives. EPOs relieve the restriction of having to designate a Primary Care Physician (PCP); they also have a wider provider network than an HMO. However, you must stay within their network, or you do not have coverage.

Is Health Insurance Different if I Have an EPO?

According to the Affordable Care Act, health insurance companies in Texas are mandated to provide the 10 Essential Health benefits. This is regardless of health care network. All HMO, EPO, and PPO plans must include the following:

•   Outpatient healthcare

•   Emergency services

•   Hospitalization

•   Pregnancy, maternity, and newborn care

•   Mental health and substance abuse disorder services

•   Prescription drugs

•   Rehab and habilitative services

•   Laboratory services

•   Preventative and wellness services

•   Pediatric, including oral and vision care

Health Insurance Benefits with an EPO

For the most part, Your Health insurance in Texas coverage does not vary if you have an EPO, HMO, or PPO. Your benefits will change as you move to a higher metal tier.

What is my copay with an EPO?

A copay is the amount you will pay when you see the doctor or seek treatment at a medical facility. An Exclusive Provider Organization (EPO) contracts with medical providers and facilities, but not all, so be cautious if you seek treatment on your own. If you are treated, and they are not in the network, you will pay out of your pocket.  

Which medical facilities will charge me a copay?

You will pay a copay when you visit a medical office or facility for treatment. Here are some common places where you will need to pay a copay:

  • Doctor or Specialist office
  • Emergency Room or Urgent Care
  • Pharmacy
  • Hospital or Outpatient Facility
  • Optometrist

Some Exclusive Provider Organizations (EPOs) charge a flat fee, while others require a percentage for services. Read your Summary of Benefits for more information.

Whether it be your provider network or copays, Cover Mile is available to assist you with understanding health insurance in Texas. We aim to guide you through the purchase process and how to choose the best policy for you and your family. Contact us today.

Frequently Asked Questions

  1. What is an EPO plan vs. HMO?

    Both Exclusive Provider Organizations (EPOs) and Health Maintenance Organization (HMO) plans require you to remain within a network of physicians and facilities. With EPOs, if you seek treatment outside of the network, you will not have coverage unless the event is an emergency. With an HMO, you can seek treatment outside of your network with approval from your insurance company. EPOs have a more extensive network of medical providers because they do not require the contracting that HMOs do. HMOs also require you to select a Primary Care Physician to coordinate your medical care; this is not a requirement for EPOs.

  2. What is an EPO medical plan at Aetna?

    Aetna offers an Exclusive Provider Organization (EPO) medical plan; however, it is only offered as part of an employer benefits package. Aetna offers three options for employers to provide benefits to their employees. If you are looking for individual options, other health insurance companies in Texas, like Oscar Insurance and Ambetter Insurance, offer EPO options for individuals and families.

  3. What is the difference between a PPO and an EPO?

    Just as there are differences between an HMO and a PPO, there are differences between a PPO and an EPO. The two types are pretty much on opposite ends of the scale. With an EPO, you are only able to see medical providers that are within your network. If you go out of network, you will not have coverage. With a PPO, you are not bound by a network of physicians or facilities. Nor do you need to request permission as you would with an HMO. However, if you choose to receive treatment out of network, your benefits will be reduced.