What is a POS Plan in Health Benefits? | PEO4YOU

Key Takeaways

• POS plans blend features of HMO and PPO plans, giving you both structure and flexibility in choosing healthcare providers.
• You’ll need a referral from your PCP to see specialists, especially for out-of-network care.
• POS plans offer lower premiums and copayments when you stay in-network, but costs increase if you go out-of-network.

Choosing a health benefits plan is crucial as it lets you make informed healthcare decisions. The plan has a POS option that will be discussed in this article. Are you trying to figure out, what is a POS plan in health benefits? While reading this article, you will understand everything from the POS plan overview to advantages and disadvantages, with a guide to finding if it’s the right one for you.

What Does POS Mean in Health Benefits?

Before we get into all the details, we should probably take a quick moment to define what POS meaning health benefits is. POS stands for Point of Service. It’s a benefits plan that is a hybrid of a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO). Policyholders have the option of using in-network or out-of-network care providers.

With a POS plan, you can choose a primary care physician (PCP), and also get referred to see out-of-network specialists, just like with an HMO plan. You can also see out-of-network doctors directly like with a PPO. The only catch is that there will likely be an increased out-of-pocket expense.

How Does a POS Plan Work?

A POS plan is a hybrid of the best of both the HMO and PPO worlds. You must choose a PCP who coordinates your care, like an HMO. You can also choose to go out-of-network for care, like a PPO, but it costs more and typically requires a referral.

Referrals are for specialists, too. POS plans almost always require you to get a referral from your PCP to see a specialist, even when you are seeking out-of-network care.

Cost-wise, the lower out-of-pocket maximums, copayments, deductibles, and coinsurance rates are associated with in-network care, while going out-of-network will result in higher out-of-pocket costs and perhaps even the need to file your own claims.

What is a POS Plan in Health Benefits Compared to HMO and PPO?

POS vs. HMO

POS plans are very similar to HMOs, with one important exception. A POS plan will let you get out-of-network care with a referral. HMOs do not. If you plan to only receive in-network care, then an HMO will be cheaper.

POS vs. PPO

POS plans are also similar to PPO plans, with one big difference. POS plans require you to get a referral from your PCP for most specialist care. PPOs usually do not have this requirement. PPOs also have a higher premium, while POS plans have a lower premium.

Benefits of a POS plan

Still not sure whether a POS plan is right for you? Here are a few more reasons to consider it:

• Lower premiums, copayments, and other out-of-pocket costs: As mentioned above, when you stay in-network, POS plans generally have lower costs.
• Flexibility to see out-of-network providers: When it’s necessary, you can go out-of-network in a POS plan — as long as you have a referral from your PCP. This is something you cannot do with an HMO.
• Primary care provider as gatekeeper: Your PCP is responsible for all of your treatment and referrals, making sure your healthcare is medically necessary and well-coordinated.
• Covered preventive services: POS plans, like all ACA-compliant plans, typically cover preventive services without additional cost. This includes a variety of services, from vaccines and screenings to annual physicals.

Disadvantages of POS Plans

Like all benefits plans, a POS plan isn't for everyone. For some, the hassle or time involved in getting a referral may not be worth it to see a specialist. If you visit an out-of-network provider, a POS plan can be more expensive than an HMO or PPO since out-of-network providers charge higher copayments and deductibles. You may also need to file claims yourself. When you see an out-of-network provider, it may also involve more paperwork on your part, and result in a delay in reimbursement.

Who Should Get a POS Plan? 

A POS plan might be a good fit if you want to lower your costs by using in-network providers but also want the flexibility of receiving care out-of-network. A POS plan may also be ideal if you don't mind having a PCP manage your care and writing referrals for you to see specialists. If you don't want a PCP and want to see any specialist without a referral, a PPO plan might be a better fit for you.

Enrolling in a POS Plan

You can enroll in a POS plan in several different ways, depending on time of year and if you qualify for certain enrollment options.

Open Enrollment Period

This is the time of the year when an individual is allowed to enroll in a health benefits coverage plan or make changes to it. It usually starts on November 1 and ends on January 15. If an individual enrolls by December 15, the coverage is effective January 1. If an individual enrolls between December 16 and January 15, the coverage becomes effective on February 1.

Special Enrollment Period

If you miss the annual Open Enrollment Period, then what you are looking for is the Special Enrollment Period. It is possible that people who missed the Open Enrollment Period may have gone through a life event that caused this. These qualifying life events may include marriage, divorce, birth or adoption of a child, moving to a new area, or loss of existing coverage.

In most cases, there is 60 days from the date of the qualifying event for you to enroll in a new plan. Other events, such as loss of Medicaid and CHIP may have up to 90 days to enroll.

Employer-Sponsored Plans

If your employer offers a POS plan as a form of group health benefit, then you should be able to enroll during your company’s annual benefits enrollment period. New employees are generally eligible to sign up for health benefits during an initial enrollment period that is usually 30 to 60 days after the date of hire.

Brokers or Agents 

You can also enroll in a POS plan by working with a licensed health benefit broker or agent. Brokers can compare many different plans and help you select the one that meet your needs. This option is available if you are not enrolling through an employer or if you need more assistance.

Cost of POS Plans

POS plans are usually priced between HMOs and PPOs, with cheaper monthly premiums but a relatively higher rate than HMOs. Deductibles will be based on the POS plan you're enrolled in. Your POS plan may also have different copayment and coinsurance for in-network versus out-of-network care. You'll pay less for using a network provider.

POS plans will require you to pay higher copayments and coinsurance for out-of-network care. POS plans typically only pay for a smaller percentage of your out-of-network costs and you may be required to file your own claim to be reimbursed for these services.

Use PEO4YOU’s Health Benefits Calculator to get fast and accurate estimates of state health benefit premiums and if you qualify for subsidies.

Frequently Asked Questions (FAQs)

What does a POS plan mean?

POS plan is a hybrid type of health benefit where you get to choose a primary doctor but can visit specialists outside the network with a referral.

Do POS plans require referrals? 

You must get a referral from your primary care physician most of the time to see a specialist.

Is a POS plan good for families?

Yes. A POS plan may be a good choice for families since it can be both affordable and flexible.

Conclusion

Selecting the perfect health benefit plan can be a daunting task. Fortunately, having a clear understanding of how a POS plan works will provide you with a solid foundation. Blending a primary care doctor structure with the ability to visit out-of-network providers as necessary, POS plans can be a great option for those who want to benefit from lower premiums without being locked into a closed network. These plans are a great option for those who want a more customizable experience.

At PEO4YOU, we’re ready and waiting to assist you with this next step in your journey. Leveraging its nationwide network of trusted PEOs, PEO4YOU can offer exceptional medical, dental, vision, and health benefit plans tailored to individuals, families and small businesses across the nation.