What is a POS health insurance plan? – Forbes Advisor

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Choosing the right plan for your needs can be difficult when you’re looking for health insurance. There are several types of health insurance available that differ in features such as out-of-pocket costs, network size, and medical services covered.

While you may be familiar with typical plans like Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans, it’s also worth considering a lesser-known plan like Point of Service (POS). In this guide, we’ll explain the basics of POS health insurance, including how much the plan costs, how it works, and how it compares to more popular plans.

What is a POS health insurance plan?

POS plans are health insurance plans that combine elements of an HMO and a PPO.

With a POS plan, you can get care from an in-network or out-of-network provider, but you pay less for in-network coverage. In this respect, it is similar to the PPO model.

Most POS plans require you to work with a primary care provider to coordinate your treatment and get a referral if you want to see a specialist. This is similar to how an HMO works.

How does a POS health plan work?

POS plans are made with a network of doctors, specialists and healthcare facilities. Network providers agree to receive a discount for the services they provide to plan members. When you visit an in-network provider, your health insurance company pays most of the bill once you reach your health insurance deductible.

With a POS plan, you are allowed to go out of network for treatment. The catch is that your insurance company pays a much smaller portion of the bill. While POS plans offer the flexibility to browse in-network and out-of-network providers, you pay the least if you get help from an in-network provider.

The only exception to this rule is emergency care. If you need to visit an emergency room or urgent care clinic, your POS plan will provide the highest level of coverage, whether the facility is in-network or out-of-network.

Before you can get specialty care under a POS plan, you need to see your primary care provider and get a referral. Examples of specialists are dermatologists, physical therapists, and cardiologists. Usually, when you first enroll, you’ll be asked to choose a primary care doctor in the plan’s network.

How much does a POS health insurance plan cost?

The average monthly cost of a POS plan is $505 for a 30-year-old$568 for 40-year-olds and $794 for 50-year-olds in the Affordable Care Act (ACA) marketplace.

The cost of a POS health insurance plan in the ACA marketplace depends on many factors. Some of the factors that affect your health insurance premium include:

Also, the cost of your plan depends on where you get your coverage. For example, individual health insurance plans purchased directly from an insurance company differ in price compared to ACA Marketplace plans. If you can get a POS plan through your employer, you can expect a much lower rate, given that employer-sponsored plans have subsidized premiums.

If you qualify, another option is to get a subsidized ACA Marketplace plan. The ACA provides subsidies and tax credits that can lower the cost of health insurance for people with family incomes below 400% of the federal poverty level.

Below are the average rates for POS plans in the ACA market based on a person’s age and situation.

Average cost of POS in the ACA market

POS ACA plans are usually more expensive than other types of health insurance plans. Here’s a look at how POS plans compare to other types of benefit plans in the ACA marketplace.

Cost of POS vs. PPO vs. HMO vs. EPO

Pros and cons of POS health insurance

POS health insurance plans have many advantages, but they also have some disadvantages. Before purchasing this type of health insurance, it is important to consider all the pros and cons.

POS pluses

  • Ability to go offline: You have the freedom to see a provider or specialist outside of the plan’s network. This gives you access to more doctors and hospitals.
  • Hybrid plan: POS plans combine elements of PPOs and HMOs.
  • Low out-of-pocket costs: Compared to other health plans, POS plans often have lower out-of-pocket costs. Some plans may also not have a deductible.

POS cons

  • Must work with a primary care provider: POS plans require that members’ health care be coordinated by a primary care provider. This can be a problem if you prefer not to name your PCP.
  • Need recommendations: Generally, you must get a referral from your primary care physician if you want to see a specialist. If you see a specialist without a referral, your insurance company may not cover the cost.
  • Not as common as other types of health care plans: POS plans are typically not offered in the ACA marketplace or by employers.

POS vs. PPO

Medical insurance PRO is one of the most common types of insurance. With PPO health insurance, you can see an in-network or out-of-network doctor, and you don’t need a referral to see a specialist. PPO health insurance is often a good choice if you feel comfortable managing your own care,

PPO and POS plans have roughly the same average monthly premiums in the ACA marketplace.

The main differences between POS and PPO

POS vs. EPO

An Exclusive Provider Organization (EPO) plan is similar to an HMO. An EPO plan covers medical services when you visit an in-network provider. If you go out of network, you are responsible for the full medical bill (except for emergencies).

But one of the benefits of EPO insurance is that you usually don’t need to work with a primary care provider or get a referral to see a specialist. Your insurance company must cover the services if the specialist contracts with the EPO network.

In terms of cost, POS plans are usually more expensive than EPO plans. In general, health insurance plans with out-of-network coverage cost more than plans that limit participants to the plan’s network.

The main differences between POS and EPO

POS vs. HMO

HMO plans often cost less than other plans. Compared to POS plans, HMO health insurance has much lower premiums and out-of-pocket costs.

Although an HMO is an affordable health insurance plan, HMO health insurance is also more limited than POS health insurance. HMO plans do not provide coverage for out-of-network care unless it is an emergency. If you visit an out-of-network provider, you must pay the full cost of the service.

Like POS plans, HMO plans also require you to work with your primary care provider and get a referral to see a specialist. Because out-of-network care is not covered, HMO members have access to a much smaller network of primary care providers, specialists, and hospitals.

The main differences between POS and HMO

Who Should Get a POS Health Insurance Plan?

POS health insurance can be a good choice if you want the flexibility to get medical care out of network. It can also be a wise decision if you already have a primary care provider overseeing your treatment and you don’t mind getting referrals to specialists.

POS plans aren’t as common as PPOs, HMOs, or EPOs, but they may work for you if you don’t want to be limited in what providers you see.

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POS Health Plan FAQs

Does the POS health insurance plan cover out-of-network health care?

Yes, the POS plan covers out-of-network service. If you go to a doctor or hospital outside of the plan’s network, your insurance company will still cover some of the cost. But your health insurance company covers a smaller percentage of the bill when you visit an out-of-network provider, so choosing an in-network provider is less expensive.

Do you need a primary care doctor if you have POS?

Yes, you need a primary care doctor if you have a POS plan. When you enroll in a POS plan, your health insurance company asks you to choose a primary care physician who will manage your care. This doctor is your main point of contact if you have questions or need a referral.

Do POS plans require a specialist visit?

Yes, POS usually requires you to get a referral from your primary care provider to see a specialist. If you see a specialist without a referral, your health insurance company may not cover the services.


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