Employee benefits, and more specifically, the healthcare industry is challenging to understand for those who don’t spend their lives in it. Even the most basic healthcare concepts, such as comparing an EPO vs PPO, can prove confusing for employers and employees.
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Exclusive Provider Organizations (EPOs), and Preferred Provider Organizations (PPOs) share many similarities, but also have distinct, separate characteristics. If your healthcare coverage provider offers both options, deciding which plan works best for you is vital and will depend on your family’s unique situation.
In this article, we’ll detail the ins and outs of each type of plan. Plus, we’ll tell you how these plans are similar and how they’re different. So, keep reading to find a complete breakdown of EPO vs PPO health insurance plans, below.
Exclusive Provider Organization (EPO)
An Exclusive Provider Organization, or EPO, is a type of health insurance plan in which members must utilize doctors and providers within the EPO network, except in case of a medical emergency. One of the most significant advantages to an EPO is participants don’t need a referral from a primary care physician to see a specialist.
EPO plans differ from Health Maintenance Organizations (HMOs) by offering participants a greater amount of flexibility when selecting a healthcare provider. But an EPO plan is like an HMO plan in that you’re responsible for paying all your out-of-pocket costs if you go out-of-network.
And while they offer less flexibility than a PPO, EPO plans are generally a little less expensive. It’s important to note that because an EPO limits your network, your existing doctor may not be a part of your EPO plan. So, if you switch to an EPO, plan you may have to find a new primary care doctor.
Preferred Provider Organization (PPO)
A Preferred Provider Organization, or PPO, is a type of health insurance plan that provides a network of healthcare providers, much like a Health Maintenance Organization. Unlike an HMO, PPO plans give participants the freedom to seek care from any in- or out-of-network provider.
Still, it’s important to know; you will pay more in out-of-pocket costs if you want to see an out-of-network provider. Even if your non-member doctor accepts the PPO rate, your plan may still make you pay an extra amount because the provider isn’t a member.
Also, under a PPO plan, like an EPO, you don’t need a referral to receive care from a specialist or hospital. The most significant advantage of a PPO over an EPO plan is flexibility. PPOs offer participants much more choice for choosing when and where they seek healthcare.
EPO vs PPO
| EPO | PPO | |
| Do I need a primary care physician? | Often, but not always. An EPO generally requires you to have a primary care doctor but varies from plan to plan. | No. A PPO doesn’t require a PCP. You can select any doctor you choose, but you will pay more for out-of-network care. |
| Do I need a referral to see a specialist? | No. If you want to see a specialist or go to the hospital, you make the appointment yourself. But the provider does have to be in-network. | No. If you want to see a specialist or go to a hospital, you make the appointment yourself. |
| Will any care I receive from an out-of-network provider be covered? | No. EPOs don’t offer coverage for healthcare from an out-of-network provider, except in case of a medical emergency. | Yes. PPOs allow you to see any medical provider, including those who are out-of-network. But you may have to pay higher out-of-pocket costs. |
| Will I have to file a claim? | No. Because EPOs restrict your care to in-network providers, you’ll most likely never have to file a claim because your insurance company pays the provider directly. | Yes. If you receive out-of-network care, you’ll have to submit your claims to be reimbursed. |
| How much will these plans cost? | Generally, lower costs. | Generally, higher costs. |
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Making a Decision
Now you know the ins and outs of both EPO and PPOs. But the question remains, which plan is right for you, or your family? When deciding between you’re an EPO and a PPO, there is a multitude of factors you must consider.
A PPO plan gives you more flexibility than an EPO by allowing you to attend out-of-network providers. On the other hand, an EPO will typically have lower monthly premiums than a PPO. But, if you’re considering an EPO, you should check approved in-network providers in your area before you decide.
There may be a lack of viable EPO providers near you, depending on where you live. In this case, your decision would be much easier. But, if you can handle an increased rigidity in your healthcare providers, an EPO may ultimately prove more valuable for you or your family.
The Wrap
So, which plan should you choose when picking between an EPO vs PPO? Well, as with most decisions in life, it depends. Still, no matter which plan you select it’s essential you completely understand your options. If its EPO vs PPO, make sure your employees know the difference. And to learn more about these plans and all other health plan types, contact The Olson Group, today!