There is no one-size-fits-all solution to health insurance. Employers can offer a variety of healthcare plans to their employees and two popular options include Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs).
Both of these plan types offer unique benefits but also have some key differences that your employees need to be aware of before they choose which type of healthcare plan to enroll in.
PPO: This plan offers high flexibility, allowing visits to any doctor or specialist without referrals, including out-of-network providers, at a higher cost.
EPO: Requires using in-network providers for non-emergency care, leading to lower premiums but no coverage for out-of-network services.
Key Differences: PPOs are best for those needing flexibility and frequent specialist visits; EPOs are suitable for those with infrequent healthcare needs and lower costs.
Let’s take a closer look at how PPOs and EPOs work.
There is no one-size-fits-all solution to health insurance. Employers can offer a variety of healthcare plans to their employees and two popular options include Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs). Both of these plan types offer unique benefits but also have some key differences that your employees need to be aware of before they choose which type of healthcare plan to enroll in. Let’s take a closer look at how PPOs and EPOs work.
What is a PPO?
A PPO plan offers a higher degree of flexibility when it comes to choosing healthcare providers. With a PPO, you can generally visit any doctor or specialist, in-network or out-of-network, without a referral. PPO plans typically do not require selecting a primary care physician, which may be preferable if you don't currently have a specific doctor you want to see. For example, let's say you have a PPO plan and need to see a specialist. You can choose any specialist you prefer and schedule an appointment. The services that the specialist provides will typically be covered by your insurance plan — even if they are not in the plan's network (but most likely at a higher cost). While the cost for that out-of-network specialist may be higher than for in-network providers, you still have the option to receive care from them.
PPOs are often a good option when employees switch healthcare coverage because their new network may not provide them with access to the same physicians they already have relationships with. If someone is receiving ongoing care, they may appreciate the stability a PPO can offer — even if they need to pay more to see an out-of-network provider.
What is an EPO?
An EPO plan operates in a more tightly controlled way than a PPO. Under an EPO, you must seek medical services from providers within the plan's network unless it's a true emergency. EPOs typically do not cover any out-of-network services (again — except emergency services). You may be responsible for the full cost if you choose to receive care outside of the network for non-emergency situations.
However, if you don't anticipate the need to visit specialists who might be out of network, or your healthcare needs are more infrequent, EPOs often have much lower monthly premiums than PPOs. For instance, let's say you visit the doctor once or twice a year, and if you need to visit a specialist, your doctor refers you. In this case, an EPO plan might be preferable as it'll be much less expensive month to month, especially if you’re visiting an in-network specialist.
EPOs may be a solid choice for healthy employees — particularly young ones — who only go to the doctor on occasion or who are worried about running into emergency healthcare costs one day.
Key Network Distinctions
As you ponder different options, here’s a quick recap of the major distinctions when it comes to PPOs vs. EPOs.
PPO Networks: As mentioned, one of the key advantages of PPOs is their flexibility. You have the option to visit both in-network and out-of-network providers. This flexibility is particularly useful if you travel frequently or prefer seeing specialists who may not be in-network. However, keep in mind that choosing out-of-network care usually involves more paperwork and higher costs.
EPO Networks: EPOs require you to stick to in-network providers for any non-emergency care. While this might seem restrictive, it often translates to lower premiums and reduced out-of-pocket expenses compared to PPOs. EPO networks are typically narrower, and care outside of this network may often not be covered, except potentially in emergencies.
To summarize for ready reference:
| Feature | EPO | PPO |
|---|---|---|
| Network Flexibility | Limited to network providers | More flexible, can see out-of-network providers |
| Cost | Generally lower premiums | Generally higher premiums |
| Specialist Visits | No referral needed (in-network) | No referral needed |
| Out-of-Network Coverage | Typically not covered | Covered, but at a higher cost |
| Suitable For | Those needing a cost-effective plan, not requiring frequent care | Those requiring more flexibility and potentially more frequent specialist visits |
Note: Tiered networks are another aspect to consider. Some states offer these tiered networks, which further classify providers into sub-categories based on cost and quality measures. Opting for preferred providers within these tiers can even lower your cost-sharing responsibilities.
Cost considerations
It’s not a secret that healthcare is an immense expense for both employers and employees. Both PPOs and EPOs have their own unique cost considerations. PPOs generally have higher monthly premiums and out-of-pocket costs in exchange for increased flexibility and coverage for out-of-network services. That being said, staying in-network for treatment can help keep costs lower than pursuing out-of-network physicians. EPOs tend to have significantly lower monthly premiums and lower out-of-pocket costs.
To help find the right fit for them and their families, your employees need to consider how often they anticipate anyone on their plan needs to see doctors other than their primary care physician. If they have chronic conditions and need to see doctors who are out of network, a PPO might be worth the extra cost. For those who visit the doctor infrequently, the reduced cost they encounter each month for premiums tends to make an EPO a more attractive option.
On the employer side, EPOs cost less, but giving your employees PPO and EPO options is a great way to ensure that they can take their healthcare needs into their own hands in whichever way they see fit.
Tax implications for companies
Providing employees with access to quality healthcare plans can help keep your workforce happy and healthy. While this is a major financial investment for businesses, you might be able to save your company some money in the process thanks to the Small Business Health Care Tax Credit.
This tax credit can cover up to 50% of the premiums you pay for your employees (35% for non-profits) for two consecutive years. To claim this tax credit, your business must enroll in a Small-Business Health Options Program (SHOP) plan. You must have fewer than 25 full-time equivalent (FTE) employees, with an average employee salary of around $56,000 or less per year. You also need to pay at least 50% of your full-time employees' premium costs and offer SHOP coverage to all full-time employees (coverage for dependents or part-time employees working less than 30 hours per week is not required).
Plan Flexibility
An EPO may be flexible enough for some, but for others, a PPO will be necessary to simplify the management of their health. Not having to seek referrals can be a big time saver and is a major perk associated with having a PPO. For example, if someone wants to see a dermatologist annually, they likely don’t want to have to jump through hoops each year just to get an annual check-up or a refill for their favorite acne medication.
Choosing the Right Plan for Your Needs
As an employer, selecting the right health insurance plan for your employees is crucial. Choosing between a PPO and an EPO can significantly impact your costs and your employees' satisfaction. Let's explore a couple of real-life scenarios to guide you in making this informed choice:
Scenario 1: A Diverse Workforce
Overseeing a company with a diverse workforce may impact your decision. Some of your employees may be young and healthy, while others might have families or chronic health conditions requiring frequent medical attention. A PPO plan might be the better option here. PPOs offer flexibility, allowing employees to choose from a wider range of healthcare providers, including those out-of-network. This flexibility can be particularly advantageous for those needing specialized care or having pre-existing relationships with certain providers.
Scenario 2: Tight Budget Constraints
Consider another scenario where your company is operating under tight budget constraints. Here, an EPO plan may be more suitable. EPOs typically have lower premiums compared to PPOs and can still provide comprehensive coverage as long as employees stay within the network. This can help manage overall healthcare costs while still providing substantial employee benefits.
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Who Should Choose a PPO Plan?
When considering a PPO plan, think about the level of flexibility and convenience you might need. PPOs are especially appealing if you prefer having a wide range of choices when it comes to healthcare providers. With a PPO, you’re not restricted to a specific network and you won't need referrals to see specialists. This can be a significant advantage if you often require specialized medical attention. Moreover, PPO plans are a sensible choice if you frequently travel or have family members living in different areas. The ability to receive care both within and outside the network means you aren't limited geographically. While this flexibility comes at a cost, it can be worth it for the ease and freedom it provides. If you need to re-enroll in a new plan and continued access to a prior set of doctors and specialists who are familiar with your medical history is important to you, a PPO plan could be the right fit. They are well-suited for individuals and families who prioritize the convenience of accessible, diverse medical care options over the potential extra expense.
Who Should Opt for an EPO Plan?
If you're looking for lower premiums and don't mind sticking to a network of providers, an EPO might be a great choice for you. EPO plans work well for individuals who prefer controlled costs and a moderate level of provider flexibility. If you don't expect to need a wide range of specialists — who may be out-of-network — the limitations of EPOs may not be a problem. Additionally, if you usually stay within the same geographic area where your network providers are located, an EPO can offer sufficient coverage without the higher cost of a PPO. On the other hand, if you need frequent out-of-network care or prefer a wide range of healthcare providers, an EPO may not offer the flexibility you need. Nevertheless, for many people, the cost savings and straightforward structure can make EPOs a practical choice for health insurance.
FAQs: Common Questions About PPO and EPO Plans
Q: Can I see any doctor with a PPO plan?
A: Yes, one of the biggest advantages of a PPO plan is its flexibility. You can see any doctor or specialist you choose, even if they are out-of- network. However, you will pay less if you stick to in-network providers.
Q: Do EPO plans require referrals to see specialists?
A: No, unlike HMO plans, EPO plans do not require you to get a referral to see a specialist, as long as the specialist is within the network.
Q: What happens if I go out of network with an EPO?
A: With an EPO, you are responsible for all the costs if you go out of network. EPO plans only cover in-network services, except in emergencies.
Q: Are PPO plans more expensive than EPO plans?
A: Generally, yes. PPO plans tend to have higher premiums compared to EPO plans due to the greater flexibility and larger provider networks they offer.
Q: Which plan offers better coverage for frequent travelers?
A: A PPO plan might be more suitable for frequent travelers since it covers out-of-network care. This can be handy if you need medical assistance while away from home and cannot access in-network providers.
Q: Can I switch from an EPO to a PPO plan?
A: This depends on your insurance provider's policies and enrollment periods. Typically, you can switch during the open enrollment period or if you qualify for a special enrollment period due to a qualifying life event.
Q: Do PPO plans cover preventative care services?
A: Yes, most PPO plans cover preventive care services like annual check-ups, immunizations, and screenings. However, specifics can vary, so it's best to check your individual plan details.
Making the right choice
Choosing between PPO insurance and EPO insurance ultimately depends on each employee’s individual needs and preferences. If they highly value the freedom to choose their healthcare providers and are willing to pay higher premiums for that flexibility, a PPO plan may be the better option for them. On the other hand, if this isn't a primary concern, an EPO plan may suit their needs better.
If you're looking for more detail on PPO vs HMO plans, check out our article on PPOs vs HMOs. You can also learn how Thatch can help with healthcare selection with a free demo.
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Jeremy Wolf, former professional athlete, is dedicated to enhancing healthcare access. As Customer Success and Broker Operations Lead at Thatch, Jeremy focus on providing customers with everything they need to navigate the complex health insurance space.
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