Can POS Plan Members Use Out-of-Network Physicians?

A Point of Service (POS) health insurance plan offers a balanced approach to healthcare coverage, blending features typically found in Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). This type of plan provides individuals with choices regarding their healthcare providers. At the core, a POS plan is designed to offer flexibility at the “point of service,” allowing members to decide how they access care. This structure aims to combine cost management with a degree of freedom in provider selection.

Understanding POS Plan Network Flexibility

Individuals enrolled in a Point of Service (POS) plan have the flexibility to seek care from out-of-network physicians. A POS plan operates as a hybrid model, combining managed care aspects of an HMO (like requiring a PCP) with the broader provider choice of a PPO. While emphasizing in-network use for lower costs, members are not strictly limited to this network.

Accessing out-of-network care within a POS plan requires a referral from the primary care physician (PCP). The PCP acts as a gatekeeper, coordinating care and issuing referrals for specialists. If a referral is obtained for an out-of-network provider, the plan may contribute to the costs, at a lower reimbursement rate than for in-network services.

Proceeding with out-of-network care without a referral often leads to higher out-of-pocket expenses, or no coverage. While the option provides greater choice, financial responsibility increases. This structure incentivizes using the plan’s network and following referral procedures.

Financial Implications of Out-of-Network Care

Opting for out-of-network care under a POS plan results in higher costs. Deductibles, amounts paid before insurance covers costs, are separate and higher for out-of-network services compared to in-network services. For example, an in-network deductible might be a few hundred dollars, while the out-of-network deductible could be several thousand.

Coinsurance, the percentage of costs paid after deductible, differs. For in-network care, coinsurance might be 10% or 20%, but for out-of-network services, it could rise to 40% or 50% of the allowed amount. This means a larger portion of the cost for each service. Similarly, out-of-pocket maximums, the maximum paid for covered services annually, are higher for out-of-network care, offering less protection against catastrophic costs.

A key consideration with out-of-network providers is balance billing. This is when a provider bills the patient for the difference between their charge and the insurer’s payment. Insurers often base payments on “usual and customary” rates, which may be lower than the provider’s charge. The No Surprises Act provides protections against balance billing for emergency and certain non-emergency services from out-of-network providers at in-network facilities. These protections do not cover all scenarios, and patients can still be balance billed in other circumstances.

The amount paid by the insurance plan for out-of-network care is lower than for in-network care. Insurers may pay only a fraction, leaving the patient responsible for the balance. This reduced payment, combined with higher deductibles and coinsurance, results in a larger financial responsibility when choosing providers outside the network.

Navigating Out-of-Network Services

When a POS plan member decides to use an out-of-network physician, understanding procedural steps maximizes potential coverage. The first step is obtaining a referral from the primary care physician (PCP). A PCP referral ensures the service is medically necessary and may qualify for higher reimbursement than if self-referred. This aligns with the managed care aspect of POS plans, where the PCP guides the patient’s healthcare.

Beyond referrals, certain out-of-network services (e.g., specialized tests, surgeries, therapies) may require pre-authorization from the insurer. This process involves the insurer reviewing medical necessity before the service is performed. Failure to obtain pre-authorization can lead to claim denial, leaving the patient responsible for the full cost. Patients must confirm these requirements with their insurer and the out-of-network provider before care.

Submitting claims for reimbursement when using an out-of-network provider falls to the patient, unlike in-network services where the provider handles billing. After receiving care, the patient must gather necessary documentation, including an itemized bill (detailing service, diagnosis, procedure codes, and amount charged). Medical records supporting service necessity may also be required.

Once documentation is collected, the patient must complete and submit the insurer’s claim form within a designated timeframe (often 90 days to a year from service date). Accurate submission is crucial for timely claim processing and potential reimbursement. Patients should retain copies and follow up with the insurer regarding claim status.