---
title: "Point of Service (POS) Plan: Meaning and Example | Riskado"
description: "A POS plan is health insurance that pays more for in-network care and less out of network, often with referrals. See a worked example and questions to ask."
url: "https://riskado.com/insurance-terms/point-of-service-plan/"
lang: "en"
published: "2026-03-17"
modified: "2026-10-01"
image: "https://riskado.com/og/default.jpg"
alternates:
  es: "https://riskado.com/es/terminos-de-seguros/plan-de-punto-de-servicio.md"
---

# Point of service plan

[Life and Health](https://riskado.com/life-and-health-insurance/) · Updated Oct 1, 2026

A point of service plan, or POS plan, is health insurance that pays one benefit level when you use in-network providers and a lower one when you go out of network. In-network care usually costs you less. Many POS plans also ask for a primary care referral before specialist care, and the plan documents set the exact rules.

Also called: pos

When your plan card or quote says POS, the practical question is where you get care. Staying inside the plan's network gets you the higher benefit level and the negotiated rates. Going outside it is usually allowed, but it can bring a separate [deductible](https://riskado.com/insurance-terms/deductible/), higher [coinsurance](https://riskado.com/insurance-terms/coinsurance/), a prior-authorization step and a bill from the provider for the difference.

## How a POS plan pays an out-of-network claim

Under Connecticut's state employee POS plan, covered out-of-network services are reimbursed at 80% of the allowable charge after the annual deductible, and prior authorization may be required, according to the [Connecticut Health Care Options Planner (opens in a new tab)](https://portal.ct.gov/-/media/AgingandDisability/documents/HR/NewEmployee/HealthcareOptionsPlannerpdf.pdf). One [claim](https://riskado.com/insurance-terms/claim/) shows how that rule plays out. The $1,000 charge and the $200 remaining deductible are illustrative; the 80% comes from the plan materials.

An out-of-network claim paid at 80% after the deductible

Hover or tap a row to highlight it.

| Step | Amount |
| --- | --- |
| Allowable out-of-network charge | $1,000 |
| Remaining deductible you pay first | $200 |
| Amount left after the deductible | $800 |
| Plan pays 80% of $800 | $640 |
| Your 20% coinsurance on $800 | $160 |
| Your total ($200 + $160) | $360 |

That $360 is only your share of the allowable charge. If the provider bills more than the plan allows, you can owe the difference through balance billing unless a federal or state surprise-billing protection applies, according to the [NAIC guide to surprise medical bills (opens in a new tab)](https://content.naic.org/sites/default/files/inline-files/New%20Protections%20from%20Surprise%20Medical%20Bills%20%281%29.pdf). Those protections cover certain emergency and facility-based services, not every out-of-network charge.

## The plan features that change what you pay

No national POS percentage or deductible applies to every plan. These features move your costs:

- **Network choice.** In-network care gets the higher benefit level. Out-of-network care can carry a separate deductible, higher coinsurance and lower reimbursement.
- **Referral rules.** A primary care referral for specialists is a standard POS feature, according to [HealthCare.gov (opens in a new tab)](https://www.healthcare.gov/glossary/point-of-service-plan-pos-plan/), but some Connecticut state POS plans do not require referrals for in-network providers.
- **Primary care physician.** Some plans require a primary care doctor to coordinate care; others allow direct access to specialists while keeping two benefit levels.
- **Cost sharing.** Each plan sets its own [copay](https://riskado.com/insurance-terms/copay/), deductible, coinsurance and annual [out-of-pocket maximum](https://riskado.com/insurance-terms/out-of-pocket-maximum/).
- **Prior authorization.** Some plans require approval before specified out-of-network services or treatments are covered.

A plan with broader out-of-network [coverage](https://riskado.com/insurance-terms/coverage/) may carry different [premiums](https://riskado.com/insurance-terms/premium/) and cost sharing than one that strongly favors network providers. The [Summary of Benefits and Coverage](https://riskado.com/insurance-terms/summary-of-benefits-and-coverage/) and the schedule of benefits control.

A POS plan sits between two other designs. It resembles a [health maintenance organization](https://riskado.com/insurance-terms/health-maintenance-organization/) because it may use a primary care doctor and referrals, and it resembles a PPO because it may cover out-of-network providers at a lower benefit level, according to the [NAIC's network plan definitions (opens in a new tab)](https://content.naic.org/sites/default/files/inline-files/committees_conliaison_network_adequacy_report_0.pdf).

## Where you will see POS

POS is a health insurance term. It shows up in individual, employer-sponsored, small-group, large-group and Medicare Advantage plans. You will see it on a quote or plan comparison page as "POS" or "Point of Service," and again in the policy, certificate, Evidence of Coverage, Summary of Benefits and Coverage, schedule of benefits and provider directory, according to the [NAIC's "Using Your Health Plan" (opens in a new tab)](https://content.naic.org/sites/default/files/publication-consumer-using-your-health-plan.pdf).

Inside those documents, look at the provider-network section, the cost-sharing table, and the referral and prior-authorization provisions. Renewal notices, explanations of benefits and claim letters use it too, often showing whether a service was processed as in-network or out-of-network. Auto, homeowners, renters, life and commercial property policies do not ordinarily use POS in this sense, so read the abbreviation in context if it appears elsewhere.

## Connecticut and New York rules for POS plans

In Connecticut, a POS plan is a managed-care plan that permits out-of-network treatment at a lower level of benefits, according to the [Connecticut Insurance Department (opens in a new tab)](https://portal.ct.gov/cid/CID-archive/Life-And-Health/Common-Terms-In-Managed-Care). State law does not set one deductible, coinsurance rate or referral rule for every POS plan. If a claim is denied, the external review and adverse determination process for health plans falls under [Conn. Gen. Stat. § 38a-591e (opens in a new tab)](https://www.cga.ct.gov/current/pub/chap_700c.htm#sec_38a-591e).

New York treats a POS product as a comprehensive in-network health benefit combined with an out-of-network indemnity benefit, under [DFS Circular Letter No. 26 (opens in a new tab)](https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2000_26). For large groups, an HMO may provide the in-network benefit while a licensed health insurer provides the out-of-network benefit, and POS premium-rating formulas must be filed with and approved by the Superintendent under rules that include [New York Insurance Law § 4308 (opens in a new tab)](https://www.nysenate.gov/legislation/laws/ISC/4308).

## Questions to ask your agent or insurer

1.  Are my primary care doctor, specialists, hospital, laboratory and pharmacy in this specific POS network? Network status sets the benefit level and can change your deductible, coinsurance and balance-billing exposure.
2.  What are the out-of-network deductible, coinsurance, copayment and annual out-of-pocket maximum? POS plans can apply separate and higher cost sharing to out-of-network services.
3.  Do I need a referral from my primary care doctor for this specialist or service? Referral rules vary by plan and can affect whether a service is paid at the expected level.
4.  Do I need prior authorization before using an out-of-network provider or receiving this treatment? Missing a required authorization can reduce or eliminate payment for a covered service.
5.  How is the out-of-network payment calculated, and can the provider balance bill me? The plan may pay a percentage of an allowable amount while the provider charges more.

## Frequently asked questions

Short answers to common POS questions.

### What does POS mean on my health insurance card?

POS stands for point of service. It means the plan pays at one level for participating providers and a different level for nonparticipating ones. In Connecticut, members of a POS plan may choose managed-care or indemnity-style benefits at the time they receive care, according to the [Office of the Healthcare Advocate (opens in a new tab)](https://portal.ct.gov/oha/health-care-plans/managed-care/health-care-definitions).

### Can I see an out-of-network doctor with a POS plan?

Often yes. Expect the plan to pay less, and check whether a separate deductible, prior authorization or balance billing applies before the visit.

### Do surprise-billing protections apply to employer POS plans?

State surprise-billing laws generally do not apply to self-insured employer plans, while federal protections may, according to the [NAIC (opens in a new tab)](https://content.naic.org/sites/default/files/inline-files/New%20Protections%20from%20Surprise%20Medical%20Bills%20%281%29.pdf). Ask your employer or plan administrator whether your plan is self-insured.

### Do POS rules differ from state to state?

Yes. POS terms and benefits vary by state and by plan. In California, a POS plan lets members go outside the network, but out-of-network charges can be much higher, according to the [California Department of Insurance (opens in a new tab)](https://www.insurance.ca.gov/01-consumers/110-health/glossary.cfm). The plan's own schedule of benefits sets the actual amounts.

## Related terms