A point-of-service plan (POS) is a type of managed care program that gives you the option to receive treatment from healthcare providers who are not in the network while simultaneously allowing you to select a primary care physician from a list of in-network doctors. You are still covered when seeking care from out-of-network healthcare providers, albeit at lower benefit levels, such as 60% or 70% of in-plan coverage. Additionally, you are in charge of completing and sending your insurance the paperwork related to your out-of-network services for reimbursement.
Learn more about point-of-service plans, including how they operate, differ from other types of projects, and their advantages and disadvantages.
Definition of a Point-of-Service Plan
A managed care plan called a point-of-service (POS) allows you to pay less if you use in-network medical facilities including clinics and hospitals. Additionally, this plan allows you the choice to visit an out-of-network physician at a greater fee or with a lower coverage level.
- Alternate names: Open-ended plan, HMO/PPO hybrid
- Acronym: POS
How a Point-of-Service Plan Works
A POS plan combines aspects of PPO and HMO policies. A POS plan functions similarly to an HMO in that it allows you to select a primary care doctor to oversee and manage your medical care. A primary care physician you choose from a list of participating healthcare professionals will need to recommend you to a specialist if necessary.
A POS plan, like an HMO plan, specifies a small copayment for in-network care, often $10 per visit or treatment. Additionally, there is no deductible while working with in-network providers.
A POS plan, like a PPO, allows you to receive care from providers outside of the network, but the cost will be higher and there may be a deductible. You must also submit a claim for your insurer’s reimbursement. You don’t require prior authorization to receive emergency medical services from out-of-network facilities or providers if you have a POS plan.
Pros and Cons of a Point-of-Service Plan
Pros Explained
- Network flexibility: A POS plan gives you more freedom to use in-network providers while getting additional medical services from out-of-network providers by combining characteristics of HMOs and PPOs.
- Lower in-network copays: The copay for an appointment in-network starts at just $10.
- Zero in-network deductible: Using in-network healthcare providers usually has no deductible. As long as your purchase is made within the POS network of suppliers, coverage begins the moment you make your first dollar.
Cons Explained
- Referrals needed: You must choose a primary care physician who supervises your medical care if you have a POS plan. Referrals are required. Before visiting a specialist, you should first speak with your general practitioner.
- Higher out-of-network copays: You can see providers outside of your network, but you may be responsible for up to 40% of the costs.
- Out-of-network deductible: Before meeting a predetermined deductible, you will not be covered for any out-of-network services.
Point-of-Service Plan (POS) vs. Exclusive Provider Organization (EPO)
Even though point-of-service plans share traits with HMO and PPO plans, how do they stack up against exclusive provider organization (EPO) plans?
While an EPO plan only covers services from hospitals, doctors, or specialists in the plan’s network, a POS plan covers medical expenses (or a portion of them) for both in-network and out-of-network providers (except during an emergency). You can visit any in-network provider, therefore you don’t require a primary care physician if you have an EPO. You’ll be charged full price if you select an out-of-network service.
| POS | EXPO |
| 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 |
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