Employee Benefits
EPO vs. PPO Insurance Plans: What's the Difference?
As open enrollment season approaches, now is a good time to learn about the different types of insurance plans, including the differences between exclusive provider organizations (EPOs) and preferred provider organizations (PPOs). Let’s take a moment to compare EPO vs. PPO insurance plans, highlight their benefits, and share some circumstances that illustrate their strengths and limitations.
What is an EPO plan?
An EPO is a health insurance plan that operates within a network of medical providers (e.g., certain hospitals, doctors, and specialists) who agree to accept negotiated fees. This means that when you visit a covered provider, you’ll pay a set percentage for any treatment and your EPO insurance provider will pay the rest.
Out-of-network providers aren’t covered under EPO plans. So, if you need to visit a doctor who’s not within the network, you may have to pay the entire bill out of pocket. However, with an EPO plan, you can see a specialist without a referral — they’ll just need to be in-network to qualify for coverage.
What is a PPO plan?
A PPO also operates within a network of hospitals, doctors, and other specialists that have agreed to accept negotiated fees for medical services.
Unlike EPOs, PPO insurance will partially cover out-of-network providers — although it will typically be at a higher cost than in-network providers. This gives policyholders more flexibility in terms of where they can receive care.
Like EPO plans, policyholders can see a specialist without a referral from their primary care physician.
Are there other differences between EPO and PPO plans?
While the primary distinction between an EPO and PPO plan is whether or not it pays for out-of-network medical expenses, there are other key differences.
Premium costs
Premiums are the monthly fees you pay for your EPO or PPO insurance coverage. EPO premiums are usually lower than PPO premiums due to their more limited coverage options.
Provider options
EPO insurance only covers medical expenses from in-network providers. If you need to see an out-of-network specialist, you’ll have to pay for medical services out of pocket — except in the case of an emergency.1
PPO insurance gives more flexibility when it comes to your healthcare, since a PPO plan will cover some out-of-network medical expenses. This can be especially valuable if you see many out-of-network providers.
EPO vs. PPO: The bottom line
EPO and PPO plans are both solid options that can help cover medical costs for you and your family. If you’re looking for coverage that reaches beyond a limited network, then a PPO may be right for you. However, EPOs tend to be more affordable and offer sufficient coverage for in-network medical services.
Your benefits coordinator or human resources (HR) representative can help walk you through PPO vs. EPO insurance options before open enrollment. They’ll help you examine plans — including health maintenance organizations (HMOs) if available — so you can make the best choice based on your budget, needs, and lifestyle.