Point of Service Plans: Copayments

One of the most comprehensive types of health insurance are provided to members who opt into point of service plans (POS). With a POS plan, policyholders have dozens of choices on how to proceed with their medical care – POS plans offer the flexibility for members to choose their own doctors and encourages them to utilize the managed care network of service providers. If you are a member of a POS plan, the copayment system will work differently depending on whether you choose your own doctor or visit a practitioner that is part of the network.

POS Plan Copayment Structure

The copayment structure for POS plans will vary for members based on the three following criteria:

  • Visiting an in-network physician
  • Getting an out-of-network referral from your primary care physician (PCP)
  • Going to an out-of-network physician without being referred by your primary care physician

With a POS managed care health plan, members are strongly encourage to use the doctors that are under the contractual obligation with the insurance company. By having doctors and hospitals under contract, the insurance company can better control the expenses associated with medical care. The insurance company knows what to expect from the doctors and hospitals under their plan and highly encourage preventive care to lower future costs. Members who opt into using the service network are charged nominal POS copayment amounts in the range of $10-$25 a doctor visit. That money is due upfront will cover any of the necessary tests the doctor orders plus additional medical care.

Out of Network Treatment

When signing up for a POS system, members must choose their primary care physician (the first doctor you’ll see) who is in charge the member’s medical guidance. If a member has a condition that will best be treated by an out-of-network provider, the PCP will refer them. At that point, based on the policy that the member has, it is typical that a deductible amount first needs to be met and then the copayment system will kick in. In this situation, the copayment is a coinsurance arrangement where both the insurance company and the member share the cost of the medical expenses. This type of out of network referral allows the copayment for the POS to be at the highest possible benefit level.

Finally, there are those circumstances where members just choose to see physicians of their choosing without getting a PCP referral. In this case, the copayment for the POS would work similar to above. Since there was no referral from a PCP, the copayment coinsurance rate would be at a “self-referral” benefit rate that would require greater out of pocket contributions from the member towards the medical expenses.