What Is A POS Health Insurance Plan? – Forbes Advisor

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Choosing the right plan for your needs can be challenging if you’re in the market for health insurance. There are multiple types of health insurance available, which differ in terms of features like out-of-pocket costs, network size and covered medical services .

While you might be familiar with common 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 this 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 that combines elements from an HMO and PPO.

With a POS plan, you can receive care from an in-network or out-of-network provider, but you pay less for going in-network. It’s similar to the PPO model in that respect.

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 the way an HMO works.

How Does a POS Health Plan Work?

POS plans contract with a network of doctors, specialists and healthcare facilities. Providers in the network agree to get paid a discounted rate 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’re 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 see providers that are in-network and out-of-network, you pay the lowest amount if you receive care from an in-network provider.

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

Before receiving specialty care with a POS plan, you need to visit your primary care provider and get a referral. Examples of specialists are dermatologists, physical therapists and cardiologists. You’re typically required to select a primary care doctor in the plan’s network when you initially enroll.

How Much Does a POS Health Insurance Plan Cost?

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

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

In addition, your plan’s costs depend on where you’re getting 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 to pay a much lower rate, given that employer-sponsored plans have subsidized premiums.

If you qualify, another option is to get an ACA marketplace plan that’s subsidized. The ACA provides subsidies and premium tax credits that can lower the cost of health insurance for people with household income at below 400% of the federal poverty level.

Here are the average rates for POS plans in the ACA marketplace by a person’s age and situation.

Average POS costs in ACA marketplace

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

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

POS Health Insurance Pros and Cons

POS health insurance plans have many benefits, but they also have some downsides. It’s important to consider the pros and cons before purchasing this type of health insurance.

POS pros

  • Option to go out-of-network: You have the freedom to visit a provider or specialist that is not in the plan’s network. This gives you access to a wider variety of doctors and hospitals.
  • Plan hybrid: POS plans combine elements of a PPO and an HMO.
  • Low out-of-pocket costs: Compared to other health plans, POS plans often have lower out-of-pocket costs. Some plans also may have no deductible.

POS cons

  • Must work with a primary care provider: POS plans require a primary care provider coordinate a member’s care. This may be an issue if you would prefer not to name a PCP.
  • Referrals are required: You generally must get a referral from your primary care provider if you want to see a specialist. If you visit a specialist without a referral, your insurance company might not cover the cost.
  • Not as common as other health plan types: POS plans aren’t commonly offered either in the ACA marketplace or by employers.

POS vs. PPO

PPO health insurance is one of the most common types of coverage. With PPO health insurance, you can visit a doctor that’s in-network or out-of-network, 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 about the same average monthly premiums in the ACA marketplace.

POS vs. PPO main differences

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’re responsible for the full medical bill (except for in emergency situations).

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

In terms of cost, POS plans tend to be more expensive than EPO plans. In general, health insurance plans with out-of-network coverage cost more than plans that restrict members to the plan’s network.

POS vs. EPO main differences

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.

While HMOs are an affordable health insurance plan, HMO health insurance is also more limited than POS health insurance. HMO plans don’t provide coverage for out-of-network care unless it’s an emergency. If you visit a provider that is out-of -network, you must pay the entire cost of the service.

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

POS vs. HMO main differences

Who Should Get a POS Health Insurance Plan?

POS health insurance could be a good choice if you want the flexibility of getting out-of-network care. It could also be a wise decision if you already have a primary care provider who oversees your care and you don’t mind getting referrals to see specialists.

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

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POS Health Plan Frequently Asked Questions

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

Yes, a POS plan covers out-of-network care. If you visit a doctor or hospital not in the plan’s network, your insurance company still covers a portion of the cost. But the health insurance company covers a lower 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 physician if you have a POS?

Yes, you need a primary care physician if you have a POS plan. When you enroll in a POS plan, the health insurance company asks you to select a primary care doctor to manage your medical care. This doctor acts as your main point of contact if you have questions or need a referral.

Do POS plans require a referral to see a specialist?

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


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