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Epo Vs. HMO

Exclusive Provider Organization (EPO) and Health Maintenance Organization (HMO) plans are two similar health care insurance plans. Both plans provide members with affordable health care coverages by controlling costs and medical services. There are differences between the coverages as well, which include premium costs, plan availabilities and network sizes that may affect the decisions of individuals and families shopping for health insurance.

  1. Plan Features

    • Both plans work on the basis of provider networks, that is, health care providers are contracted to provide medical services for members at discounted rates in exchange for business. These plans require members to stay within their provider networks to receive insurance benefits and to take advantage of the lower service costs. As a result, members pay no deductibles and small co-payments for in-network care.

    Considerations

    • EPO and HMO plans require members to choose Primary Care Physicians (PCPs), doctors who are responsible for coordinating their patients' medical decisions. PCPs have the authority to refer their patients to other doctors and specialists for treatments but can deny medical procedures if they are deemed unnecessary.The availability of these plans is a consideration as well. HMO plans, which covered 66 million people nationwide in 2010, according MCOL, publishers of health care business news, have large networks making them less able to serve rural areas where providers may be few and far between. EPOs, with their smaller networks, can be a better fit.

    Differences

    • There are several differences between the two plans that affect the members as well as medical providers. For example, the physician networks of EPO plans are smaller than HMO plans. The premium rates of EPO plans are generally cheaper than HMO plans according to the website MedHealthInsurance. This could be partly because health care providers from both plans are paid differently. For example, health care providers receive regular monthly per-patient payments from HMO insurers while doctors contracted with EPO plans are paid only after performing medical services.

    Warning

    • Members of HMO and EPO plans face paying all of their medical expenses out-of-pocket if they go out of network for care. However, HMO members who get referrals from their PCPs will receive full coverage for these visits. Also, HMOs will pay for non-network visits without referrals if they are considered emergencies. As for EPO members, in addition to not receiving any insurance coverage for non-network doctor visits, they will only receive partial insurance benefits for emergency care received out-of-network.

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