EPO plans fall somewhere between HMOs and PPOs in terms of both cost and coverage.
Medicare Advantage plans (Part C, also known as MA) must cover everything Original Medicare does, and they often also offer additional benefits. For example, an MA plan may provide coverage for routine hearing or vision exams, dental, and gym memberships or other wellness benefits.
The four main types of Medicare Advantage plans are:
- Health maintenance organization (HMO)
- Preferred provider organization (PPO)
- Private fee-for-service (PFFS)
- Special needs plans (SNP)
Another type of MA plan you may see is an exclusive provider organization plan (EPO). An EPO plan is a type of managed care plan, which means your plan will cover most of your medical expenses as long as you visit an in-network provider. There are a number of key features and benefits to these plans, as well as considerations to take into account when deciding which type of plan is right for you.
Here is more information about EPO plans, as well as other options to help you compare.
What is an EPO plan?
When you have an EPO plan, only in-network care is covered. If you see or visit an out-of-network provider or hospital, you'll likely pay for the full cost out-of-pocket (except for in an emergency).
The good news is EPO provider networks are typically larger, so you have more options when it comes to receiving care.
Some EPO plans do not require you to choose a primary care provider (PCP), and you can usually see a specialist without a referral. However, because you don't have to have a PCP, you're more likely to need pre-approvals before receiving certain medical services. If the plan doesn't authorize the care, it won't pay for it, and you'd be responsible for all costs.
Even if an EPO plan does require you to select a PCP, that can be helpful when it comes to managing your healthcare. PCPs can provide preventive care and services, as well as treatment for both minor and chronic illnesses, to help keep you healthy.
When it comes to cost, EPO plan premiums are typically higher than HMO plans but lower than PPO plans. You may also have a higher deductible, which means you must pay more out-of-pocket before the plan starts covering your expenses, but there will be a maximum out-of-pocket for the plan.
For emergencies only
If you do not want to get a referral to see a specialist, want a lower monthly premium, and don't mind seeing an in-network provider for care, an EPO plan may be right for you.
What are provider networks?
A provider network is the list of doctors, hospitals, specialists, durable medical equipment (DME) suppliers, and other providers that a plan is contracted with to provide medical care to its members. When you see these providers, known as in-network providers, you'll typically pay less.
Providers who are not contracted with the plan are considered out-of-network and you'll usually pay more out-of-pocket. Some out-of-network provider services aren’t covered at all, and you'd have to pay the full cost.
Depending on the type of MA plan you choose, care may only be covered for in-network services, or it may be covered for both in- and out-of-network care but with a higher co-payment.
When comparing plans, it's important to understand the provider network to ensure you get the care you need from your preferred providers or hospitals at the lowest cost. You can usually find the plan's provider directory on their website or contact the plan directly for more information.
Cost of EPO plans
The cost of an EPO plan varies depending on the insurance carrier, where you live, and the plan you enroll in. These plans typically have lower premiums and out-of-pocket costs (as long as you stay in network), including co-pays and co-insurance.
Enrolling in an EPO plan
To find an EPO plan, you can use our Find a Plan tool. Just enter your zip code to begin reviewing Medicare plans in your area. You can also call us toll-free to talk to one of knowledgeable Medicare agents, who will answer your questions in language you can easily understand (no Medicare speak here!).
The best time to enroll in an EPO plan is during your Initial Enrollment Period (IEP), which begins 3 months before your 65th birthday, includes your birthday month, and ends 3 months later. Or, you can join an Advantage plan during the Annual Enrollment Period, which is from October 15 through December 7 each year.
You may also qualify for a Special Enrollment Period (SEP), which allows you to enroll in a new plan outside of open enrollment if you have what Medicare calls a "special circumstance," such as moving outside your plan's service area or losing employer coverage. Find the full list of qualifying special circumstances on Medicare.gov here.
To join a Medicare Advantage plan, you can:
- Sign up online
- Call the plan
- Talk to a Medicare broker like ClearMatch Medicare
- Call Medicare
- Submit a paper application
Be sure to compare different plans in your area to find the one that's right for you and your health and circumstances.
Difference between HMO, PPO, and EPO plans
The two most common types of Medicare Advantage plans are HMO and PPO. Deciding which type of plan is right for you depends on your unique situation.
EPO vs. PPO
While an EPO plan requires you use in-network providers, a PPO plan allows you to see both in- and out-of-network providers, though you'll pay less when you use a preferred provider.
PPO plans do not require selecting a primary care doctor and you don't need a referral to see a specialist.
Premiums for PPO plans may be higher and may have higher co-pays, especially if you regularly see out-of-network providers. However, PPO plans typically have a lower deductible.
Yes, but at a higher cost
EPO vs. HMO
HMO and EPO plans are similar because you must use in-network providers; otherwise, your services may not be covered. You also have to choose a PCP when you have an HMO plan, and you must get a referral to see a specialist.
The good thing about HMO plans is they typically have lower premiums and co-pays as long as you stay in-network.
For emergencies only
Are you ready to join a Medicare Advantage plan?
Our licensed insurance agents can help you understand your Medicare plan options. Just call us toll-free to get started.
Medicare.gov: Who Can Join a Medicare Advantage Plan?
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ClearMatch Medicare: How to Compare Medicare Advantage Plans
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