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Point of Service (POS) Plan Information

Highlights

  • Review how a Point of Service health plan works.
  • Understand the pros and cons of POS plans.
  • Consider your family's typical medical needs before choosing an insurance plan.
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Point of Service (POS) Plan Information

You have many choices, when shopping for the right health insurance plan. One option is a Point of Service plan, also known as a POS plan.

How a POS Plan Works

A POS plan is a unique form of managed care health insurance. A POS plan combines attributes from both HMOs and PPOs. For example, Point of Service plans have smaller deductibles for most care and very limited co-payments, compared to a PPO. A co-payment is an amount paid at the time of treatment to offset a portion of the medical costs. The amount of the co-pay varies depending on the specific medical treatment. Medical office visits have a different co-payment rate than prescriptions and more involved medical treatments.

Like an HMO, POS plans also have a network of physicians, hospitals, and other medical providers. POS plans require you to select a primary care physician (PCP). A PCP is your gatekeeper regarding all health-related issues. You can see a specialist or other care provider only if your PCP refers you; you cannot go to an in-network specialist directly without prior approval of the PCP.

Similar to a PPO, POS plans also offer limited coverage to members who choose to go out-of-network for medical care. However, the out-of-network coverage is significantly less than that of in-network coverage, and requires a deductible and co-payment. A deductible is a dollar amount the POS requires a member to pay out-of-pocket before the member can begin to be reimbursed for his/her medical expenses. The deductible amount is normally an annual sum with the deductible applying each calendar year. However, some Point of Service plans have exceptions and offer carry-over deductible features.

Why a Point of Service Plan

POS plans offer more freedom and choices than an HMO. Even if you go out-of-network for some of your medical needs, you are still covered, at least to a certain degree. HMOs, for example, do not cover you if you go outside of the HMO network of providers. With a Point of Service plan, members do get some coverage.

POS plans have smaller deductibles for most care and limited co-payments for in-network coverage, compared with a PPO. With a PPO, members are required to meet deductibles and pay co-payments.

Why not a Point of Service Plan

In a POS plan, like in a PPO, if you go out-of-network for your medical care, your coverage is limited and you will have higher out-of-pocket expenses. Visiting an out-of-network provider also requires you to pay a deductible and a much higher co-payment. If your preferred medical caregiver is not in your POS plan, you could end up spending more for your medical needs. POS plans generally have higher co-insurance than a PPO.

Also, a POS plan requires members to choose a primary care physician (PCP). Even if a specialist is in their POS network, members still need approval from their PCP before they visit the specialist, if they want to be covered by their POS plan.

Summary

A Point of Service plan may be a good choice for your medical coverage. It combines benefits from both HMOs and PPOs, but a POS plan is not the best choice for everyone.

Before you decide on a Point of Service plan, read all the fine print. Consider your family’s specific medical needs. Look at your typical medical costs and find the right coverage that covers the standard medical care you need at a cost you can afford.

3.5
/5.0
(25 Votes)