Point of Service (PoS) Plans offer reduced cost sharing to insureds who utilize in-network physicians and providers. Similar to Health Maintenance Organizations (HMO), insureds designate a PCP from within the network, and must get referrals from their PCP in order to see specialists. As with a PPO, insureds can see out of network physicians and other providers, but they must cover most of the expenses associated with such visits. There is an exception – if the PCP refers the insured to a specialist outside the network, then the plan will usually cover the visit as “in-network.”
Point-of-Service (PoS) Plans are types of managed care plans that are a cross between an HMO and a PPO plan. Much like with HMO’s insureds designate a physician – In-Network – to be their Primary Care Physician (PCP). However, just like a PPO, insureds can still go outside of network for plan services. When insureds do go out of network, they must pay most of the cost, unless the primary care physician has provided a referral to the out-of-network provider. In that case, the group health plan will cover the expenses according to the plan.
Generally, a PoS plan provides access to health plan services at an overall lower cost, but with fewer choices. Plans vary, but generally, PoS plans are a hybridized version of an HMO and PPO plan. Insureds can access care from in-network or out-of-network physicians and providers; however, their level of coverage will be more advantageous in-network. Often, insureds will be required to get referrals from your primary care physician (PCP).
The terminology, “point of service,” refers to what physician or provider you receive plan services. Coverage under the plan will vary depending on whether the insured sees a physician in-network or out-of-network, and if a referral is required by the plan.
In PoS plans, an insured will select a Primary Care Physician (PCP) that helps coordinate health care for the insured. Costs will be lower if insureds see in-network physicians and providers. Much like a PPO, insureds have choices about where they can receive plan services. A PCP may refer patients to in-network specialist physicians, if the PoS plan requires. Insureds may also see out-of-network physician specialists, absent a referral, but could likely pay additional amounts.
PoS Plans enjoy many advantages, such as costs are typically lower, specialists are often available outside of the plan’s with more out-of-pocket, reduces claims paperwork despite having gone out-of-network.
The downsides to PoS Plans, depending on the plan, a referral from a PCP may be required to see in-network specialists. Accessing plan services from outside the network, costs may be higher than they would be in-network. While there should be less paperwork in general, insureds utilizing out-of-network plan services may be responsible for additional claims paperwork, management of receipts and bills.
Depending on plan design and the insurance carrier or plan, features of a PoS plan may differ. PoS plans work best when the terms of the plan are followed. If insureds can be comfortable in the selection of a primary care physician (PCP), PoS plans can be a good fit. However, even if a PoS plan overall cost is lower, businesses and insureds may pay higher costs if they should need to see a physician outside the plan network. Small businesses and insureds should check to see if physicians and other providers are in-network before choosing a plan.
