Exclusive Provider Organization: An Ultimate Guide

Forget about HMO and PPO plans and find out why EPO plans are sweeping the nation.

FirstQuote Health Staff
Published on
February 3, 2023
Last Updated on
October 6, 2023
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EPO, or Exclusive Provider Organization, is becoming a common term in health insurance. It is similar to PPO and HMO plans, however EPO plans offer fewer coverage options due to the lack of out-of-network providers associated with the plan. This means that members are limited to receiving care from a select group of healthcare providers in order to receive coverage. It is important for individuals to understand the differences between EPO and PPO/HMO plans when selecting their health insurance so that they can receive the most cost effective service possible.

What is an EPO Plan?

An EPO plan is an Exclusive Provider Organization health insurance plan. This type of health insurance plan only allows members to receive coverage from a limited network of healthcare providers, usually within the same geographic area. EPO plans often offer more affordable rates than PPO or HMO plans, and they also have fewer restrictions when it comes to seeking care outside of the immediate provider network.

However, this can mean that members may not get access to specialists or treatments that may be available at other facilities.k. Exclusive Provider Organizations have a mutually benefiting relationship with health insurance companies in that, the network of health care providers provides services to subscribers of the plan who are later reimbursed by the insurers. The medical services are offered at a relatively lower price than other general medical services. The healthcare providers then get business by having a constant inflow of patients who are subscribers of the plan.


What is an HMO Plan?An HMO plan, or Health Maintenance Organization, is another type of health insurance that offers members coverage within a network of healthcare providers. The difference between an EPO and an HMO lies in the restrictions placed on members when seeking care outside of their immediate network. While EPO plans offer fewer restrictions, HMO plans require members to obtain referrals from their primary care physician before they can see any specialists or receive treatments from out-of-network providers. Additionally, HMO plans typically have higher premiums due to the broader scope of coverage for members.

Here's a list of comparisons between EPO and HMO

  • Restrictions: HMO plans restrict their members to a network of pre-approved providers, and may also require referrals from a primary care physician before specialist visits are allowed. EPO plans offer a greater selection of providers, but they don’t typically have the same restrictions that HMOs do. However, EPO plans often come with higher out-of-pocket costs for treatments and procedures. Additionally, it’s important to note that some special medical conditions may be excluded from certain EPO or HMO plan coverage altogether.
  • Cost: HMO plans typically have much lower premiums than EPO and other PPO plans, however they also offer fewer choices when it comes to providers. EPO plans may offer a wider choice of providers, however they will often come with higher out-of-pocket costs as well as higher premiums. Ultimately, the cost of an insurance plan will depend on the coverage offered by the particular plan, so it's important to make sure you compare all options before making a decision.
  • Specialists and Treatments: EPO plans generally allow members to visit specialists without a referral from a primary care physician. This is in contrast to HMOs, which usually require referrals before specialist visits can be made. Additionally, EPO plans may offer coverage for specialty treatments that aren’t provided by the limited network of providers within HMO plans. However, the coverage and extent of special care available will vary greatly between different EPO and HMO plans.
  • Geographic Area: HMO plans have the most restrictive geographic coverage when compared to EPO and PPO plans. HMO members can usually only receive care from providers within their assigned plan's network, usually within a single region or state. An EPO plan may cover care in multiple states, with coverage typically being concentrated in one area, while PPO networks often span across much wider regions or even nationwide.


A PPO plan, or Preferred Provider Organization, is similar to an HMO in that members select a network of healthcare providers. However, the big difference between PPO plans and EPO plans is that PPO plans allow for more flexibility when it comes to seeking care outside of the network. While members of an EPO plan may not be able to receive any out-of-network benefits, members of a PPO plan will have the option to access out-of-network services at higher rates. Additionally, while both types of plans require preauthorization for treatments, PPOs don't require members to get referrals from primary care physicians in order to see specialists.

Here's a list of comparisons between EPO and PPO

  • Restrictions: With an EPO plan, members can generally see any specialist they choose without a referral from their primary care physician. In contrast, with a PPO plan, referrals are usually required in order to see specialists and obtain certain treatments. Additionally, since an EPO plan is limited to a specific geographic area, treatments may not be available if the member is outside of that zone.
  • Cost: An EPO plan often has more affordable rates than a PPO plan due to the limited network of providers. However, should members of an EPO need treatments outside of their immediate area, they may end up paying more for those services. This can be mitigated by opting for a PPO plan that offers coverage in a larger geographic region.
  • Specialists and Treatments: EPO plans typically offer fewer restrictions on seeking care outside of the network than PPO plans. With an EPO plan, members can generally see any specialist they choose without a referral from their primary care physician. However, treatments may not be available if the member is outside of the zone specific to their plan. On the other hand, with a PPO plan, referrals are usually required in order to see specialists and obtain certain treatments, but there is greater flexibility in terms of where members receive treatment.
  • Geographic Area: EPO plans generally limit care to a much smaller geographic area than PPO plans. This means that members of an EPO plan may need to travel further to access the care they require, which can come with additional costs and time commitments. Because PPO plans offer coverage in larger regions or even nationwide, they allow more flexibility when it comes to seeking treatment outside of one's immediate area.


Deciding between HMO, PPO and EPO plans is truly a personal decision. To make the best choice for your situation, it’s important to consider the cost and coverage of each type of plan. With HMOs, you will likely pay lower premiums but have more restrictions on provider selection. With PPOs and EPOs, you may have more flexibility in terms of providers but higher out-of-pocket costs and higher premiums. Ultimately, you should compare all options before settling on one plan so you can find the one that offers the best overall balance of cost and coverage for your needs.

How to Get an EPO Plan?

Comparing different EPO plan offerings from various providers is essential for finding the best overall fit for your needs. When considering different plans, look for factors such as monthly premiums, co-pays, deductibles and out-of-pocket maximums. Additionally, consider what types of medical care or procedures are covered or excluded by the plan, any limitations on provider selection, and any limits on out-of-network coverage. Typically, you can find this information on the health insurance provider’s website or by speaking to a representative from the company. Generally, EPO plans cover preventive care and emergency services without any cost sharing. However, other types of services may be subject to copays and/or deductibles depending on the specifics of the plan. Additionally, some plans may limit coverage to in-network providers only so be sure to check if that applies before signing up for a policy. Finally, pay attention to customer service ratings for the plan’s provider so you have a good understanding of the level of support you can expect.

FirstQuoteHealth can help you find an EPO plan by offering a comprehensive comparison of different plans from numerous providers. The website allows users to search and compare plans based on specific criteria, including coverage type, provider network, covered services, and overall costs. Additionally, we provide detailed information regarding each plan and its associated benefits so users can make informed decisions about which one best suits their needs. If a user needs more help or has questions about the plans available, FirstQuoteHealth also provides helpful customer support staff who can offer guidance and advice.

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