A point-of-service plan (POS) is a form of managed care program that lets you choose a primary care physician from a list of in-network providers while also giving you the freedom to seek treatment from out-of-network health care providers. You’re covered when you seek care from out-of-network health care providers but at reduced benefit levels, for example, 60% or 70% of in-plan coverage. You’re also responsible for filling out and submitting your out-of-network service paperwork to your insurer for reimbursement.
Learn more about a point-of-service plan, how it works, how it differs from other plans, and the pros and cons of this healthcare coverage.
Definition of a Point-of-Service Plan
A point-of-service plan (POS) is a managed care plan that lets you pay less if you use in-network hospitals, doctors, and health care providers. This plan also gives you the flexibility to see an out-of-network provider at a higher cost or reduced benefit level.
- Alternate names: Open-ended plan, HMO/PPO hybrid
- Acronym: POS
How a Point-of-Service Plan Works
A POS plan combines features of both HMO and PPO plans. A POS plan works like an HMO because it lets you choose a primary care physician who will coordinate and monitor your health care. You’ll pick a primary care physician from a list of participating providers, and you’ll need a referral from them if you need to seek specialist services.
Similar to an HMO plan, a POS plan designates a nominal copayment amount for in-network care, usually around $10 per visit or treatment. Also, there’s no deductible for using in-network providers.
Like a PPO, a POS plan lets you seek care from out-of-network providers, but you’ll pay a higher cost than you would incur with an in-network provider and you may have a deductible. In addition, you must also file a claim for reimbursement by your insurer. With a POS plan, you don’t need pre-approval before receiving emergency care services from out-of-network facilities or providers.
Apart from emergency services, you may have to pay the full cost of all other benefits and services you receive from an out-of-network provider.
Pros and Cons of a Point-of-Service Plan
Lower in-network copays
Zero in-network deductible
Higher out-of-network copays
- Network flexibility: By blending aspects of HMOs and PPOs, a POS plan offers more freedom of choice to use in-network providers while obtaining other health care services from out-of-network providers.
- Lower in-network copays: The in-network copay starts as low as $10 per appointment.
- Zero in-network deductible: There’s typically no deductible for using in-network health care providers. Coverage takes effect from the first dollar you spend, provided it’s within the POS network of providers.
- Referrals needed: In a POS plan, you must select a primary care physician who coordinates your medical care. You must consult your physician before seeking care from a specialist.
- Higher out-of-network copays: You are able to see out-of-network providers, but you may need to cover up to 40% of the costs.
- Out-of-network deductible: Coverage for out-of-network care won’t begin until you meet a specified deductible amount.
Point-of-Service Plan (POS) vs. Exclusive Provider Organization (EPO)
A point-of-service plan has the characteristics of both HMO and PPO plans, but how does it compare to an exclusive provider organization (EPO) plan?
While a POS plan covers health care costs (or a portion thereof) for both in-network and out-of-network providers, an EPO plan covers only services from hospitals, doctors, or specialists in the plan’s network (except during an emergency). As a result, you don’t need a primary care doctor with an EPO since you can visit any in-network provider. If you choose an out-of-network provider, you will be responsible for all costs.
|You need a primary care doctor||You don’t need a primary care doctor|
|You can use both in-network and out-of-network providers||You can only use providers within the EPO’s network|
|Your POS may pay for a portion of your out-of-network care if you have a referral||Your EPO won’t pay for services received out-of-network|
- A point-of-service plan combines aspects of PPO and HMO plans.
- A POS plan gives participants more freedom to use out-of-network providers.
- A POS policyholder is responsible for completing and submitting their out-of-network service paperwork for reimbursement.
- You won’t pay a deductible on your POS plan when you use in-network providers.