EPO vs. PPO: What's the Difference?

EPO vs. PPO: What's the Difference?

Between Medicare plans, prescription drug plans, and other health care services and programs, it's tough to keep track of all the medical program acronyms out there.

If you've been researching medical insurance options, chances are good that you're familiar with the acronym HMO, but what about EPO vs. PPO?

Choosing between a Preferred Provider Organization (PPO) and an Exclusive Provider Organization (EPO) can be tough because, at first glance, they offer similar services.

Here we'll discuss the features of each and the subtle differences between them so you can make an informed decision about which one is the best fit for your health and medical care needs.

PPO Health Insurance Plan

A PPO offers members a "preferred" network of local health care providers and hospitals. However, keep in mind that you won't get assigned to a primary care physician, although PPOs may give members access to out-of-state health care providers as "in-network" services when necessary.

You won't need a referral to see a specialist, and you'll only pay for some of the cost of seeing a health care provider. If you decide you want to see someone outside of your PPO, however, expect to pay at least part of the total cost.

EPO Health Insurance Plan

An EPO has some similarities to both HMOs and PPOs. Your options for health care have some flexibility, as with a PPO, but your premiums are still manageable.

An EPO often requires members to have a primary care provider. It covers out-of-network care only in the case of emergencies, and if you want an appointment with a doctor outside of your network, you are responsible for the cost. Like a PPO, EPO health insurance does not require that you get a referral if you want to see a specialist.

EPO vs. PPO: Key Differences

At first glance, it might be tough to see the differences between an EPO vs. PPO, but there are a few. First, a PPO doesn't need a Primary Care Provider (PCP) to help arrange and coordinate medical and health care services, but an EPO might. For example, if you suspect you need to meet with a rheumatologist regarding arthritis in your hands, you will need to meet with your PCP first, who will then send a referral to a rheumatologist.

Second, an EPO comes with lower premiums than a PPO, but only emergency care will be covered if you decide to get care from outside the plan network.

Third, your care options are more limited with an EPO because the network of health care providers is smaller and more localized. Keep this in mind if you live in a rural or low-population area where you might need to travel long distances for medical services.

Which Plan Is Right for You?

Both EPOs and PPOs have pros and cons that can help guide your decision.

An EPO provides a local network of health care professionals and hospitals and comes with lower premiums and a higher deductible. If you're in relatively good health, you don't expect significant medical costs, you understand you'll likely pay full price for care outside the local network and you consider affordable health care your main priority, an EPO may be right for you.

If you value the ability to choose your health care professionals from a larger network, you like the idea of a wider range of hospitals and you're willing to pay higher premiums for this flexibility, a PPO could be a better fit. A PPO could also be a better choice if you know you will have significant medical costs.

When it comes to EPO vs. PPO, flexibility and cost are two key considerations. Make sure you know the features, pros and cons of each before you make your decision so you can choose the right plan for your situation.

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