POS Plan

A hybrid plan design

A POS plan, short for point of service, is a mix of an HMO and a PPO. The name comes from the idea that you choose how to use the plan at the point of service, each time you get care.

Typical POS rules:

• You pick a primary care physician who coordinates your care.
• You need a referral from that doctor to see most specialists.
• You can go out of network, but at a higher cost, and sometimes only with a referral.

Example

Luis owns a small restaurant and has a POS plan through a group policy for his staff.

• His primary care doctor refers him to an in-network cardiologist after an abnormal test. He pays in-network cost sharing.
• He wants a second opinion from a cardiologist at an out-of-network university hospital. With a referral from his primary doctor, the plan covers part of it at the out-of-network rate. He pays a higher deductible and coinsurance, plus any amount the hospital bills above what the plan allows.
• Without the referral, the plan might cover less or nothing for that visit.

Pros of a POS plan

• Some out-of-network coverage, unlike an HMO or EPO.
• Coordinated care through a primary doctor.
• Premiums often lower than a comparable PPO.

Cons of a POS plan

• Referral requirements add steps.
• Out-of-network costs can be high, and balance billing can apply.
• Two sets of cost-sharing rules make bills harder to predict.

Where you will find POS plans

POS plans are less common in the individual market than HMOs, EPOs and PPOs. You are more likely to see them in employer group coverage. If you own a business and are comparing a small group plan against options like an ICHRA, you may see POS plans on the group side.

Marketplace vs private plans

On the Marketplace, availability depends on your county, and many areas offer no POS plans at all. Private individual plans outside the Marketplace generally use PPO networks instead. For most people buying their own coverage, the real decision is between HMO or EPO plans on the Marketplace and PPO-style plans privately.

Questions to ask about any POS plan

• Which services need a referral, and does out-of-network care require one?
• What are the separate out-of-network deductible and maximum?
• Are my current doctors in network, or would I be paying out-of-network rates?

Business owners weighing group options should read our small business owner health insurance guide. If you want a straight comparison of plan types for your team or family, start your quote.