Is a POS Plan More Like an HMO or PPO?

A traditional POS plan is closest to an HMO with an added benefit for care outside the network. It usually uses a primary-care provider to coordinate treatment and specialist referrals, while also covering some care from nonparticipating providers at higher member costs.

POS stands for point of service. Some versions allow direct specialist appointments and work more like a PPO. Before choosing, check how the specific plan handles referrals and how its benefits change when you use different providers.

Where POS fits between HMO and PPO

Open-access POS plans and individual products can use different referral rules.

The HMO similarity: A primary-care starting point

Traditional POS coverage builds on the HMO approach of working with a primary-care provider. That clinician treats everyday health concerns and arranges referrals when someone needs a specialist. HealthCare.gov’s description of POS plans follows this model.

For an employee with ongoing knee pain, the first step might be an appointment with their primary-care provider, followed by a referral to an orthopedist. Following the plan’s referral process can affect how that specialist visit is covered.

Some POS products remove the referral requirement. Some Aetna POS coverage, for example, allows members to use providers inside or outside the network without referrals. The benefit documents explain which process applies to your coverage.

The PPO similarity: Benefits outside the network

POS and PPO plans can both cover eligible care from nonparticipating providers. That may give someone a way to continue seeing a longtime specialist who hasn’t joined the plan’s network.

The outside-care benefit usually comes with higher costs. There may be a separate deductible, a larger percentage of the bill to pay, and a possible charge above the amount the plan recognizes. That last charge is called balance billing.

Suppose a plan recognizes $150 of a nonparticipating therapist’s $250 bill and pays 60% after the deductible has been met. The plan pays $90. The member’s 40% share is $60, and a permitted $100 balance bill would bring the member’s total to $160. This hypothetical example shows why the percentage alone doesn’t tell you the full cost of a planned outside appointment.

Emergency care and certain services at in-network facilities have separate surprise-billing protections.

A POS plan may have more than two provider levels

Some designs offer separate benefits for a main provider system, other contracted providers, and nonparticipating providers. Two doctors can both participate in the plan but carry different deductibles or copays because they’re in different benefit levels.

BHT’s guide to Kaiser coverage explains a regional POS arrangement with three provider levels. It also shows why similar plan labels can produce different bills for an appointment, test, or hospital stay.

For a planned procedure, confirm the surgeon’s benefit level and the facility’s. Ask whether spending in one level also counts toward the deductible in another, and which charges count toward the plan’s annual spending limit.

Compare the care route and the bill

A POS plan can suit someone comfortable starting with a primary-care team who also wants benefits for outside care. A PPO may offer a more direct route to specialists, although its actual referral rules and outside-care benefits still need a look.

Business Health Trust works with Washington employers and their brokers to compare those details. Bring the providers employees want to keep and a likely care scenario, such as recurring therapy or a planned operation. Compare the referral process, provider levels, deductible, and member costs alongside the monthly premium.