Point of Service Plans

A Point of Service plan provides the financial benefits of an HMO with the freedom of a PPO.

Point of Service simply means that the patient has the option, at the time services are needed, to use the HMO side of the plan, the PPO side of the plan or they can choose to select a provider that is out of network.

A Point of Service plan can function like an HMO in the sense that a patient can choose to receive care, from preventative services to specialty care, from providers that are enrolled under the HMO portion of the plan. When HMO providers are used, the patient will incur little, if any, out of pocket costs; in most cases just a copay.

HMO plans are restrictive by limiting access to the HMO panel of doctors only; with no coverage for any out of network services. The plan will include a large team of in network providers, from all specialties, in which to choose from.

Point of Service plans can also function like PPO plans. The patient is not restricted to using only in network providers. They have the freedom to see any provider they choose, in or out of network, no referral required, as long as they are willing to pay the increased out of pocket costs.

So, maybe a patient with a POS plan hears about a great new dermatologist across town that is not in the HMO network, but, they may be part of the PPO network or they could even be completely out of network.

Here lies the true beauty of a Point of Service plan, the patient could decide to be treated by this dermatologist and have all medically necessary services be paid at the in network or out of network benefit level.

The patient may or may not end up paying more out of pocket, but nothing beats having the freedom to choose.

With a Point of Service plan a patient can continue to see an HMO provider for treatment of high blood pressure, have weekly chiropractic visits by an in network PPO provider and arrange to see that great out of network dermatologist all at the same time.

EXAMPLE OF A POS PLAN

Providers that participate under Point of Service plan can be reimbursed by capitation, contracted rate, fee for service or any other methodology as determined by the carrier.

ADVANTAGES & DISADVANTAGES OF POS PLANS

Advantages to Members Participating in POS Plans

  • Greater freedom to choose by whom and where to have services rendered.
  • The ability to pull the highest benefit from the plan by using all levels at the same time, if needed.
  • The ability to have access to specialized, maybe even holistic care with some level of reimbursement forthcoming.

Disadvantages to Members Participating in POS Plans

  • Low reimbursement for out of network providers means more out of a member's pocket.

Advantages to Providers Participating in POS Plans

  • Access to a larger volume of new patients.
  • More control over health care decisions.

Disadvantages to Providers Participating in POS Plans

  • Reimbursement may not be adequate enough to justify the increase in patients.

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