Point of Service Plans

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You have chosen a POS health insurance plan because you can get care both from a service network of providers and choose your own physicians as well. POS (point of service plans) are a type of managed care health insurance that acts as a hybrid of an HMO and a traditional health care plan.

POS Network Basics

A POS plan has numerous doctors, hospitals, surgeons and other health practitioners under contract. With this contract, the insurance company can better manage their expenses as can gauge what the actual expense for treating a member will be. Additionally, the POS network encourages preventative medicine such as regular check ups and annual health screens, which encourages their members to follow a healthy lifestyle on their own.

POS Referrals

When a person decides to become a certificate holder of a POS network, they will first have to choose a primary care physician (PCP). This PCP will then become the official liaison between the member and the insurance company. In order for a member to get the most cost-effective health care through their POS network, they need to visit their PCP for basic care (such as check ups), and can see a specialist both in and out of the network when they need to.

POS plan members should visit as many in-network service providers as possible, as that will help control costs. Deductibles are non-existent or extremely low for in-network care and copayments are either waived or run about $10-$25 per visit.

In general, the network portion of a POS managed care health plan operates very similarly to an HMO plan.

POS plans are a type of managed care health plan that grants policyholders the ability to see both in and out of network practitioners. Within a managed care health insurance system there is a system of doctors, hospitals and health practitioners under contractual obligation through the insurance provider. When an individual chooses to sign up for managed care, the first thing they will need to do is choose a primary care physician (PCP). With a POS plan, the member can see both doctors within the service network and outside of the policy. If the member has a condition for which they want to go outside of the service network for treatment, they still must get a referral from their PCP.

Primary Care Physicians

PCPs act as the gatekeepers for POS plans. To help manage the overall cost to the insurance companies, the PCPs are really the first line of defense to ensure that any additional treatment by a specialist is actually necessary. The member must first see the PCP, discuss their condition, and the PCP will then work closely with them to decide the most beneficial path for treatment including making the necessary referrals for the POS plan to contribute to the expenses.

Many POS plans also pay coinsurance for those appointments that are considered a "self-referral." Self-referral is when the patient opts to visit a doctor outside of the service network system without getting authorization from their PCP. When this occurs, typically the rate of coinsurance contribution the medical insurance will kick in is a lower percentage than if someone follows the proper POS referral steps.

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