Find out how you can use a POS plan to go out-of-network or save money with in-network care.
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.
POS insurance coverage routes care through your PCP like an HMO, with in-network cost benefits like a PPO. You are required to select an in-network PCP 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.
POS 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 and need specialized care that is only available outside of your geographic area.
POS insurance is a managed care health insurance plan. You’re provided a list of PCPs 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 copay.
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 copay for care from an out-of-network provider will also be higher.
POS 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 vs. PPO
POS plans offer flexibility and moderate pricing by comparison in exchange for adhering to some restrictions similar to those imposed by HMO plans.
Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.
Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.
Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.