What is a POS health insurance plan? – Forbes Advisor

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Choosing the right plan for your needs can be tricky if you’re in the health insurance market. There are several types of health insurance available, which differ in features such as reimbursable expenses, network size, and medical services covered.

While you might be familiar with the common plans, like Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans, it’s also worth considering a lesser-known plan. , such as Point of Service (POS). In this guide, we’ll explain the basics of POS health insurance, including how much this plan costs, how it works, and how it compares to more popular plans.

What is a POS health insurance plan?

POS plans are health insurance that combines elements of an HMO and a PPO.

With a point-of-sale plan, you can receive care from an in-network or out-of-network provider, but you pay less to get in-network. It is similar to the PPO model in this respect.

Most POS plans require you to work with a primary care provider to coordinate your treatment and get a referral if you want to see a specialist. This is similar to the operation of an HMO.

How does a POS health plan work?

POS plans contract with a network of doctors, specialists, and healthcare facilities. Network providers agree to be paid at a discounted rate for the services they provide to plan members. When you visit an in-network provider, your health insurance company pays most of the bill once you reach your health insurance deductible.

With a POS plan, you are allowed to go out of the network for treatment. The catch is that your insurance company pays a much smaller portion of the bill. While point-of-sale plans offer the flexibility to see providers who are in-network and out-of-network, you pay the lower amount if you receive care from an in-network provider.

The only exception to this rule is emergency care. If you need to go to the emergency room or an urgent care clinic, your point-of-sale plan will provide the highest level of coverage, whether the facility is in-network or out-of-network.

Before you receive specialized care with a POS plan, you should see your primary care provider and get a referral. Examples of specialists are dermatologists, physiotherapists and cardiologists. You usually need to select a primary care physician from the plan’s network when you first sign up.

How much does a POS health insurance plan cost?

The average monthly cost for a POS plan is $505 for 30 year olds$568 for 40s and $794 for 50s in the Affordable Care Act (ACA) market.

The cost of a POS health insurance plan in the ACA market depends on several factors. Some of the factors that affect your health insurance premium include:

Also, your plan’s costs depend on where you get coverage. For example, individual health insurance plans purchased directly from an insurance company differ in price from plans in the ACA marketplace. If you can get a POS plan through your employer, you can expect to pay a much lower rate, since employer-sponsored plans have subsidized premiums.

If you qualify, another option is to get a subsidized ACA market plan. The ACA offers grants and premium tax credits that can lower the cost of health insurance for people whose household income is less than 400% of the federal poverty level.

Here are the average POS plan prices in the ACA Marketplace based on a person’s age and status.

Average point of sale costs in the ACA market

POS ACA plans are generally more expensive than other types of health insurance plans. Here’s a look at how POS plans compare to other types of perk designs on the ACA marketplace.

Cost of POS vs PPO vs HMO vs EPO

Advantages and Disadvantages of POS Health Insurance

POS health insurance plans have many advantages, but they also have some disadvantages. It is important to consider the pros and cons before purchasing this type of health insurance.

Point of sale professionals

  • Ability to leave the network: You have the freedom to consult a supplier or a specialist who is not in the network of the plan. This gives you access to a wider variety of doctors and hospitals.
  • Hybrid diet: Point-of-sale plans combine elements of a PPO and an HMO.
  • Low disbursements: Compared to other health plans, POS plans often have lower out-of-pocket costs. Some plans may also have no deductible.

Disadvantages of point of sale

  • Must work with a primary care provider: POS plans require a primary care provider to coordinate a member’s care. This can be a problem if you prefer not to name a PCP.
  • References are needed: You usually need to get a referral from your primary care provider if you want to see a specialist. If you see a specialist without a referral, your insurance company may not cover the costs.
  • Not as common as other types of health plans: POS plans are generally not offered in the ACA marketplace or by employers.

POS vs PPO

PPO health insurance is one of the most common types of coverage. With PPO health insurance, you can see a doctor in-network or out-of-network, and you don’t need a referral to see a specialist. PPO health insurance is often a good choice if you feel comfortable managing your own care,

Both PPO and POS plans have roughly the same average monthly premiums in the ACA market.

Main Differences Between POS and PPO

POS vs. EPO

An Exclusive Provider Organization (EPO) plan is similar to an HMO. An EPO plan covers medical services when you visit an in-network provider. If you go outside the network, you are responsible for the full medical bill (except in an emergency).

But one of the benefits of EPO insurance is that you usually don’t need to work with a primary care provider or get a referral to see a specialist. Your insurance company must cover the service if a specialist contracts with the EPO network.

In terms of cost, POS plans tend to be more expensive than EPO plans. In general, health insurance plans with out-of-network coverage cost more than plans that restrict members to the plan’s network.

Main Differences Between POS and EPO

POS vs. HMO

HMO plans often cost less than other plans. Compared to POS plans, HMO health insurance has much lower premiums and out-of-pocket expenses.

While HMOs are an affordable health insurance plan, HMO health insurance is also more limited than POS health insurance. HMO plans do not cover out-of-network care except in emergencies. If you visit an out-of-network provider, you must pay the full cost of the service.

Like POS plans, HMO plans also require you to work with a primary care provider and get a referral to see a specialist. Since out-of-network care is not covered, HMO members have access to a much smaller network of primary care providers, specialists, and hospitals.

Main Differences Between POS and HMO

Who should enroll in a POS health insurance plan?

POS health insurance might be a good choice if you want the flexibility to get out-of-network care. It might also be a wise move if you already have a primary care provider overseeing your care and don’t mind being referred to specialists.

Point-of-sale plans aren’t as common as PPOs, HMOs, or EPOs, but they might work for you if you don’t want to be limited in the providers you see.

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POS Health Plan Frequently Asked Questions

Does a POS health insurance plan cover out-of-network care?

Yes, a POS plan covers out-of-network care. If you go to a doctor or hospital that is not part of the plan’s network, your insurance company still covers part of the cost. But the health insurance company covers a lower percentage of the bill when you visit an out-of-network provider, so choosing an in-network provider is cheaper.

Do you need a primary care physician if you have an outlet?

Yes, you need a primary care physician if you have a POS plan. When you enroll in a POS plan, the health insurance company asks you to select a primary care physician to manage your medical care. This doctor acts as your main point of contact if you have questions or need a referral.

Do POS plans require a referral to see a specialist?

Yes, an outlet usually requires you to get a referral from a primary care provider to see a specialist. If you see a specialist without a referral, your health insurance company may not cover the services.


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