What You Need To Know
It’s possible to see out-of-network providers, but you’ll pay more than you would if you choose an in-network provider.4
When you’re trying to figure out which health insurance plans allow you to see different healthcare providers, think about the lunch aides at recess.
If your lunch aide was easygoing, she’d let you play with anyone and everyone. If she was strict, you’d only get to play with students in your class. And if she was moderate, she’d let you play with anyone on the playground, as long as you asked permission first.
A preferred provider organization (PPO) plan is similar to the easygoing lunch aide; you should be able to see any provider you like, in-network or out-of-network, without asking permission. A health maintenance organization (HMO) is like the strict lunch aide; you can only see in-network providers, if you want coverage for your visit. And a point-of-service (POS) plan is like the middle-of-the-road lunch aide: You have to ask your primary care provider (PCP) for a referral before seeing other providers, but you can see anyone who’s in-network or out-of-network. There are advantages to visiting in-network providers in POS plans, but you have some flexibility to see other providers, if you prefer.1
How Does a Point-of-Service Plan Work?
Health insurance companies create networks of healthcare providers who agree to accept set fees for services.5 People who pay the lowest monthly premiums6 typically have HMO plans, which don’t allow them to see providers outside the network except for emergency and urgent care visits.7
For a slightly higher monthly premium,8 a POS plan gives you the option of seeing out-of-network providers, although it’s to your advantage to see in-network providers.9 When you see out-of-network providers, your deductible, coinsurance10 and copayment11 will be higher than for in-network providers. Fees are higher outside the network because your insurance plan hasn’t negotiated for lower costs.12
People with POS insurance are usually13 – but not always14 – required to choose a primary care physician. Whenever you want to see a provider, you’ll need a referral from your PCP, whether you’re seeing an in-network or out-of-network provider.15
What Are Benefits of a Point-of-Service Plan?
If your doctors happen to be members of your health insurance plan’s network, POS coverage may help you save money, because fees will be lower than for out-of-network doctors.
If you want the freedom to occasionally see any provider, including someone outside of your plan’s network, a POS plan will allow you the ability to go out-of-network and still receive coverage.16
What Are Drawbacks of a Point-of-Service Plan?
Having a POS plan means that you’ll have to see your primary care provider every time that you want to see another doctor. If you don’t like the idea of having your PCP as gatekeeper, a POS plan may not be right for you.17
If you never plan to see an out-of-network provider, you’ll pay higher premiums for a POS plan than you would with an HMO plan.18 An HMO plan typically requires members to visit in-network providers only.19
With a point-of-service plan, your primary care doctor must refer you to see other providers.
How Does a POS Plan Differ from an HMO Plan?
A POS plan is similar to an HMO plan, up to a point: Both have networks of providers that offer services at rates that the insurance company has negotiated. Both plans usually require you to choose a PCP and get referrals in order to see other providers.
But people with HMO plans aren’t able to have any appointments with out-of-network providers covered by insurance, while people with POS plans are.20
How Does a POS Plan Differ from a PPO Plan?
A POS plan and a PPO plan have some of the same elements, but they also differ in certain ways. Both have networks of providers that have agreed to offer services for lower fees. Both offer the flexibility to see in-network or out-of-network providers. With both plans, costs are higher if you go out-of-network.
One big difference between POS and PPO plans is that people with PPO plans don’t need PCP referrals to see providers, but people with POS plans do.21
Monthly premiums tend to be higher for a PPO plan than a POS plan.22
How Does a POS Plan Differ from an EPO Plan?
A POS plan offers more flexibility than an exclusive provider organization (EPO) plan. With an EPO, you must see providers within the network to receive insurance coverage. With a POS plan, it’s possible to go out-of-network.23
How Much Does a Point-of-Service Plan Cost?
Costs vary by the plan, but POS plans tend to have higher monthly premiums than HMO plans and lower monthly premiums than PPO plans.24 The deductible, coinsurance and copayment amounts will be lower when you see in-network providers, compared to out-of-network providers.25
How Common Are Point-of-Service Plans?
POS plans are not very common. More people are covered by PPO and HMO plans. Fewer than 10 percent of people who get health insurance coverage through employers are enrolled in POS plans.26
Is a Point-of-Service Plan Right for You?
Decide whether you’ll want to see your PCP every time that you want to see another provider, or if you’d rather have the ability to see any doctor at any time. Figure out whether or not you want to be able to see any doctors you choose, whether they’re in-network or out-of-network.27
In or Out
A point-of-service plan allows you to see in-network and out-of-network providers.
When choosing a health plan, determine your comfort level with provider appointments before you focus on monthly premiums. Do you want to see a PCP for referrals before seeing other providers? Do you want the option of visiting doctors outside of your network? These answers will help you figure out if you’re comfortable with a POS plan or if another option would be better.28