EPO vs. PPO

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Navigating the myriad of health insurance plans available can be incredibly complex, with seemingly an avalanche of acronyms and abbreviations being thrown around. This article will compare Preferred Provider Organizations (PPO) and Exclusive Provider Organizations (EPO) to help you understand the difference between these types of health insurance plans when it comes to making the best decision for you.

Similarities

Both EPO’s and PPO’s provide access to a network of health service practitioners through paying premiums to the insurance company the organization works with. Within the network, health care services are typically provided at a deep discount compared to the regular list price uninsured people would pay for services in the discount.

Differences

While broadly there are many similarities between the two types of organizations there are also some important differences that can influence your decision on which to choose.

• Out of Network Visits: When visiting a health care provider outside of your plan network you will often still receive a partial reimbursement from a PPO plan (though they pay far lower than if you visit within the network). With an EPO you will not receive any reimbursement for visits outside of the network.
• Network Size: EPO’s tend to be far smaller than PPO’s with networks that are regional or even limited to citywide coverage. PPO’s typically span the nation so if you need to visit a health service provider anywhere in the country there is likely someone in your network there. Aside from geographical considerations, there is also a significant difference in the total number of health providers in the network. You will have far fewer choices in terms of specialists and other health providers, essentially seeing the one or two specialists available in the network.
• Overall Cost: EPO’s tend to be cheaper than PPO’s due to the lower cost structure that results from both of the differences noted above. So if cost sensitivity is a major issue EPO’s can be a good solution for many individuals.
• Primary Care Physicians: It is not uncommon for EPO’s to require that you have a primary care physician in the network who would have to refer you to see any specialists. You should check if this is a requirement with any EPO you are considering as essentially you’re paying to see a doctor just so that you can pay to see another doctor.

So What’s the Best Choice for Me?

When choosing between an EPO and a PPO cost is usually the key decision-maker, as EPO plans can be accessed for far less than many PPO’s. When making this cost trade-off it’s very important to ensure that the EPO network you are considering has all of the specialists you may require based on your health needs. You also want to ensure you carefully consider the implications of travelling outside of the network. If it’s something you do regularly you would potentially not have access to network providers. When deciding between an EPO vs. a PPO you need to weigh all of these considerations carefully and ensure that you pay special attention to the key differences noted in the section above. You also of course need to research reviews of the specific organizations you are considering as you can often see what current and past clients of the network have to say.

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