POS and PPO plans can both provide benefits for care outside their provider networks. A POS plan commonly gives a primary care doctor a larger role in coordinating specialty care, while a PPO generally offers more direct access to specialists. The exact referral rules and outside-network costs depend on the plan.
For employees who want to keep particular doctors, compare where those doctors participate and what each plan would pay for their care.
What does POS stand for?
POS stands for point of service. These plans combine network-based care with benefits for eligible services from outside providers. Some use several provider tiers, each with its own deductibles and costs.
A POS plan may coordinate specialty care through a primary care doctor. Referral requirements can also change with the provider tier, so look at the rules for the doctor you intend to see.
What does PPO stand for?
PPO stands for preferred provider organization. Members usually pay less when they use participating providers and more for covered care outside the network.
PPOs generally allow specialist appointments without a primary care referral. Check the specific plan and specialist’s scheduling requirements before booking. A PPO designation also doesn’t establish how extensive its outside-network benefits are.
Benefits of POS vs. PPO
A POS plan can suit employees who prefer a primary care team to coordinate care while keeping an option to use other providers. A tiered design can offer different ways to receive treatment at different costs.
Suppose an employee uses the plan’s main care system for regular appointments but wants to keep an outside specialist. Compare whether that specialist is in another participating tier or is fully out-of-network. The bill could be very different.
Benefits of PPO vs. POS
A PPO can offer a simpler route to specialists for someone arranging their own appointments. A suitable regional or national network may also support family members who need routine care in different locations.
Check the exact network for each location. Two PPOs can include different hospitals, and a doctor who accepts one product from an insurer may not participate in another.
POS vs. PPO rules
Washington’s insurance commissioner describes POS plans as usually requiring specialist referrals, while PPOs generally don’t. Individual products can work differently, including different rules within the same plan.
Referral rules are separate from prior authorization. Both types of coverage may require the insurer to review certain procedures or treatments before you receive them. Ask who will arrange that review, especially when using an outside provider.
POS vs. PPO costs and covered services
Review the deductible and coinsurance at every provider tier. Ask whether spending in one tier counts toward the deductible or spending limit in another.
Outside-network care can also involve balance billing. As a hypothetical example, a provider charges $300, the plan recognizes $200, and your coinsurance is 40% after the deductible. You could owe $80 in coinsurance plus the $100 difference, for a total of $180. Surprise-billing protections apply to emergency care and certain other services.
An outside provider may require payment first and leave you to submit a claim for reimbursement. Check that process and whether outside-network spending has an annual limit.
POS vs. PPO: Which is better?
Compare the route to care, provider participation, and the full year’s costs. A POS plan may fit employees who value coordinated care and can use its lower-cost provider tier. A PPO may fit employees who prefer to arrange specialty care directly and need its particular network.
Business Health Trust and your broker can put the available Washington options side by side. Ask them to trace an ordinary specialist appointment and a planned procedure through each plan, including referrals, authorization, the facility, and the employee’s share of the bill.