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Insurance and Healthcare Consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity product.

Point-of-Service (POS) health insurance plans offer benefits that vary depending on where you receive care. These plans provide the freedom to seek care from out-of-network providers without a referral and opt for in-network care with cost benefits.

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What You Should Know About POS Plans

  • PCP required: Your primary care physician will coordinate your in-network care.
  • Out-of-network coverage: Care out-of-network doesn’t need to go through your PCP, but will cost more.
  • Between an HMO and PPO: POS plans have features that are somewhere in the middle of HMO and PPO plans.

What is POS Insurance Coverage?

POS insurance coverage routes care through your primary care physician like an HMO, with in-network cost benefits like a PPO. You are required to select an in-network primary care physician who acts as the coordinator of your care with a POS. Your PCP provides primary and preventive care services and referrals to in-network specialists as needed.

Unlike HMO plans (and similarly to PPO plans), you can do so without a referral if you seek care outside of the network. But the coverage will not be as robust. You will need to pay more for out-of-network care than if you had chosen to remain in-network. The amount of coverage provided by the insurance company will depend upon whether the point of service is in-network or out-of-network.

POS plans have higher premiums than HMO plans but cost less than PPO plans. This ‘somewhere-in-the-middle’ pricing makes sense, as this type of plan combines the best of the two options.

Each POS plan is unique and has its terms. In most cases, you will be responsible for filling out and filing claims and other paperwork for out-of-network medical care, and copayments required for out-of-network service will be higher than that owed for in-network care. There is usually a deductible to be met before out-of-network coverage begins, while in-network care does not require meeting a deductible.

Point of Service plans are particularly attractive if you want to save on medical expenses and want the ability to see physicians or receive care from health care providers who are not in the plan’s network. The plans are also beneficial if you travel frequently need specialized care that is only available outside of your geographic area.

How Does POS Insurance Work?

POS insurance is a managed-care health insurance plan. You’re provided a list of PCP doctors from whom you can choose that will provide all your primary medical needs, including preventive care, annual physicals, and sick visits. If care is required from a specialist, the PCP will refer you to one who is within the network.  This care is completely covered with no deductible and only a nominal co-pay.

If you choose to seek care outside of the network, you can do so without a referral. The service you receive will be covered, but you will be required to meet an out-of-pocket deductible before coverage begins, and the plan will pay a smaller percentage of the fees. Your co-pay for care from an out-of-network provider will also be higher.

How Do POS Plans Differ From Other Types of Health Insurance?

Point-of-service plans offer some aspects of both HMO plans and POS plans, but they are also different from each other in many ways.

POS vs. HMO

  • POS plans allow you to seek care from both in-network specialists (with a referral) and out-of-network specialists and health care providers.
  • No referrals are needed for care from out-of-network specialists, but less coverage will be provided, and co-pays will be higher.
  • POS plans have higher monthly premiums than HMO plans.
  • POS plans impose a deductible that must be met before coverage is provided for care from out-of-network providers.
  • With a POS, you need to prepare and submit paperwork for claims with out-of-network providers.

POS vs. PPO

  • POS plans require you to choose a Primary Care Provider (PCP).
  • POS plans require referrals for in-network providers.
  • POS plans usually have lower monthly premiums than PPO plans.
  • POS plans do not impose a deductible for coverage provided for care from in-network providers.

What Are The Advantages And Disadvantages of POS Insurance?

POS plans offer flexibility and moderate pricing by comparison in exchange for adhering to some restrictions similar to those imposed by HMO plans.

Advantages Disadvantages
  • Monthly premiums are lower than those of PPO plans.
  • Ability to see a specialist outside of the approved network and to have care covered.
  • When receiving services from an in-network provider, there is no deductible, lower co-pay, and all paperwork is taken care of.
  • If you travel or need care that is only available outside of their geographic area, it’s covered.
  • Monthly premiums are generally higher than those of HMO plans.
  • Referrals are required to see a specialist in the approved network.
  • Before coverage is provided for services from an out-of-network provider, you must meet a deductible.
  • When receiving services from an out-of-network provider, the copays are higher.
  • When receiving services from an out-of-network provider, you’re required to complete and file all required paperwork and coordinate all payments.

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