POS Plan Definition | OnlineHealthIns.com Glossary

POS (Point of Service) Plan

Also known as: Point of Service Plan

A hybrid health plan that requires a primary care physician and referrals like an HMO, but still allows out-of-network care at a higher cost like a PPO.

A POS (Point of Service) plan blends features of an HMO and a PPO. As with an HMO, you choose a primary care physician who coordinates your care and provides referrals to specialists. As with a PPO, you have the option to go out-of-network, though it costs more and usually requires more paperwork.

A PCP referral is generally required to see a specialist, even in-network.
Out-of-network care is allowed but reimbursed at a lower rate.
Premiums typically fall between HMO and PPO pricing.

The tradeoff with a POS plan is that you get some of the flexibility of a PPO while keeping the coordinated-care structure of an HMO. That can mean lower costs than a full PPO, but with the added step of needing referrals before you can use that out-of-network flexibility.

People sometimes assume a POS plan lets you skip referrals when going out-of-network. In most POS plans, the referral requirement still applies, and skipping it can mean the plan pays even less, or nothing, for that out-of-network visit.

Example

A member on a POS plan gets a referral from their PCP, then chooses to see an out-of-network specialist on that referral and pays a higher coinsurance share than they would in-network.

Good to Know

Skipping the referral step on a POS plan can reduce your reimbursement even for in-network care, not just out-of-network care.

Related Terms

HMO (Health Maintenance Organization) — A health plan that covers care mainly through a network of contracted providers and usually requires you to pick a primary care physician and get referrals to see specialists.

PPO (Preferred Provider Organization) — A health plan that gives you a network of preferred providers for the lowest cost, but still lets you see out-of-network providers and specialists without a referral.

Network (In-Network / Out-of-Network) — The group of doctors, hospitals, and other providers that have agreed to accept a health plan's negotiated rates; using providers outside that group usually costs more.

Coinsurance — The percentage of a covered service's cost you pay after meeting your deductible, with your insurance plan paying the rest.