Question

POS
(Point-of-Service) Plans
If I want to see a doctor outside of my network, I...

Answer 1

...will generally still be able to get some coverage, but you’ll pay more and you usually must follow special rules.

Key points about POS plans:
- You normally pick a primary care physician (PCP) and need a PCP referral/authorization to see a specialist. That referral requirement usually applies whether the specialist is in- or out-of-network.
- Seeing an out-of-network doctor typically means higher cost-sharing (higher deductible and higher coinsurance) and possible balance billing (the provider can bill you for the difference between their charge and what the plan reimburses).
- You may have to file the claim yourself when you use an out-of-network provider; in-network providers usually submit claims for you.
- Emergency care is generally treated as in-network regardless of where it’s provided, but non‑emergency out-of-network visits are handled under the higher out-of-network benefit level.
- Some POS plans allow you to self-refer to out-of-network providers but at greater cost.

What to do before you go:
1. Check your plan’s summary of benefits or call member services to confirm out-of-network coverage, required referrals, deductibles, and coinsurance rates.
2. Ask if prior authorization or a referral is required and have it obtained by your PCP if needed.
3. Verify whether the out-of-network provider will accept your insurance or expects full payment up front.
4. Keep and submit all receipts and itemized bills if you must file a claim.

If you want, tell me your insurer/plan name and I can help find the specific rules for your POS plan.