Point of Service (POS) Health Insurance Plans

Point of service (POS) health insurance plans give consumers the chance to take advantage of network-based cost savings without the restrictions associated with most forms of managed care.

Like preferred provider organization (PPO) health insurance plans, point of service plans fill a minor but specific niche in the health insurance market.

They account for only a small number of plans but play an important role in rounding out market offerings to ensure that all consumers can find the combinations of cost and convenience they need.

Like other forms of managed care, POS insurance plans use networks of providers and facilities to make quality care available to consumers at below-market prices.

However, similar to PPO plans, point of service plans give enrollees the option to access some out-of-network care.

POS plans can be highly affordable. They are often available without deductibles, which can appeal to consumers who do not want or who cannot afford to spend potentially large amounts of money out-of-pocket when they need care.

The Role of Primary Care Providers in POS Plans

Point of service plans, like health maintenance organization (HMO) insurance plans, look to primary care providers to serve as guides and gatekeepers. Enrollees in POS plans must select qualifying providers to serve as their primary care physician (PCP).

Policyholders’ PCPs must belong to their POS’s provider network. In the point of service PCP-as-gatekeeper model, health insurance enrollees are typically required to get referrals from the primary care providers before seeing a specialist.

In-Network Versus Out-Of-Network Care

Although POS plan enrollees must choose PCPs from their providers’ networks, they do have the option to access out-of-network care if they wish. Primary care providers may refer patients to in-network or out-of-network specialists.

All specialist visits must be pre-approved and properly referred by patients’ PCPs in order to qualify for coverage. Enrollees will receive discounted rates for care if they use in-network providers and facilities.

Out-of-network care will be covered at a lower rate than in-network care, even with appropriate referrals. This means that finding the right health insurance plan for you of your family

The Benefits of POS Plans

Point of service plans allow health insurance enrollees a relatively large amount of freedom, while also delivering the cost savings associated with managed care provider networks.

Policyholders have the ability to select and access care from any providers, regardless of their affiliation with their plans’ networks. This is particularly beneficial for patients who:

  • Travel frequently.
  • Already have existing, unaffiliated specialist providers they want to continue using.
  • Prefer to have a large degree of control to the providers and facilities they receive care from.
  • Want the convenience of accessing after-hours care through local clinics and other local, flexible, highly available out-of-network facilities.
  • Live in areas with extremely limited provider options.

In POS plans, patients also benefit from dedicated primary care providers. PCPs can play a key role in coordinating and guiding care. This is often especially important for patients with chronic conditions or complex health care needs.

It can also strongly benefit patients who need additional support for managing the logistics or continuity of their care passed preventive health care services.

Like most managed care plans, point of service plans allow enrollees to access emergency care whenever and wherever it is available without penalty. However, POS plans’ willingness to pay for a portion of out-of-network care costs can offer enrollees additional peace of mind.

HMO plans, for instance, may spell out the definition of “emergency” situations in detail and refuse to pay for care that does not meet their criteria. With a POS plan, enrollees can confidently access emergency care whenever they feel it is appropriate.

Even if the care does not fully qualify as “emergency” care under a POS plan’s statutes, patients can count on having at least a portion of the costs offset by their insurance. Prospective enrollees should review the costs of health insurance coverage prior to selecting a plan.

Policyholders who utilize mostly in-network providers can often expect POS plans to be fairly low cost. Plan premiums are almost always lower than those of PPO plans, although they are generally higher than those of HMO plans due to the flexibility they offer.

Some point of service plans will require policyholders to pay deductibles, others will not. Copayments, when they apply, are usually modest. Enrollees may pay as little as $10 to $25 for in-network appointments and services.

The Drawbacks of POS Plans

Although POS plans can be extremely affordable, they are not guaranteed to be low cost. Some plans may require deductibles to be met before insurance coverage kicks in.

Enrollees who access large amounts of out-of-network care, which is covered at lower rates, may end up spending more than they expected out-of-pocket in deductibles, copays and other costs.

POS enrollees must find primary care providers who belong to their plans’ networks. This can present challenges to patients who already have a PCP they like who is not part of the network or those who do not like any of the approved PCPs within their plans’ networks.

Additionally, seeing a primary care provider first each time patients want or need to see a specialist can extend the amount of time it takes to get specialist care. If patients’ PCPs do not agree that specialist care is warranted, then they can refuse to provide a referral.

When that happens, patients are faced with the choice of not receiving the desired care or paying the entire cost of specialist care out-of-pocket. Even when PCPs do provide referrals, they may not be willing to provide them to the in- or out-of-network specialists patients wish to see.

This, again, puts patients in the unwelcome position of complying with care that is not what they wanted or paying wholly out-of-pocket for other alternatives.

POS plans are generally excellent at providing care in a timely fashion with a minimum of paperwork when that care is delivered by in-network providers. That efficiency is one of the key benefits of managed care networks of all kinds.

When policyholders receive care from out-of-network providers that efficiency often breaks down. Patients can face complicated claims processing procedures. They may end up waiting extended periods of time for their claims to be processed and for reimbursements for their health care expenses to be paid to them.

Many potential enrollees experience confusion regarding what exactly their potential costs would be under a POS plan, which often drives them to select other types of plans, instead.

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