Quick answer
A point-of-service (POS) plan usually has you pick a primary care doctor and get referrals to see specialists, like an HMO. Unlike most HMOs, it also pays for some care outside its network, though your share is higher and an out-of-network provider can bill you for charges above what the plan allows. POS plans are uncommon: 8% of covered workers in employer plans were in one in 2026, and about 7% of 2026 Marketplace plans were POS plans.
Key takeaways
- POS plans usually ask you to choose a primary care doctor, and HealthCare.gov says they require a referral from that doctor to see a specialist.
- You can use out-of-network providers for a higher cost, though many POS plans require a referral from your primary care doctor first.
- Out of network, you may have to file the claim yourself and pay the difference between the provider’s charge and the plan’s allowed amount.
- In KFF’s 2026 employer survey, published October 22, 2026, 8% of covered workers were in POS plans, compared with 50% in PPOs.
- Every plan’s Summary of Benefits and Coverage lists its plan type at the top, next to “Plan Type.”
On this page
How a POS plan works
What you pay in a POS plan depends mostly on whether the doctor or hospital is in the plan’s network.
In the network, a POS plan works much like an HMO. You usually have a primary care doctor who handles routine care and sends you to specialists when you need one. KFF describes POS plans as plans with lower cost sharing in network that use a primary care gatekeeper for specialist and hospital visits. Network providers bill the plan directly, so you usually just pay your copay, coinsurance or deductible.
Outside the network, the plan still pays something, which an HMO generally doesn’t. Your share is usually much higher than it would be in network. Many POS plans require a referral from your primary care doctor before they’ll pay for out-of-network care, so check the plan’s rules before you go.
What out-of-network care can cost
Going out of network in a POS plan often means more paperwork and more risk:
- Claim forms: An out-of-network provider may not bill your plan, so you might pay the provider and then file a claim yourself to get reimbursed. See how to file a health insurance claim.
- Balance billing: The plan pays based on its allowed amount. An out-of-network provider can bill you for the rest of their charge. In-network providers can’t do that for covered services.
- Out-of-pocket maximum: Out-of-network spending usually doesn’t count toward your in-network out-of-pocket limit, and neither do charges above the allowed amount.
Here’s how that adds up. Say an out-of-network doctor charges $100, the plan’s allowed amount is $70 and your out-of-network coinsurance is 40%, with your deductible already met. The plan pays $42 and you owe $28 in coinsurance. The doctor can also bill you the other $30, so you pay $58 in all.
The No Surprises Act protects you from most surprise bills for emergency care and for out-of-network clinicians who treat you at an in-network hospital or facility. It doesn’t cover ground ambulances, and it generally doesn’t help when you choose an out-of-network doctor for planned care outside an in-network hospital or facility. For more, see what to do about out-of-network costs.
POS vs. HMO, PPO and EPO
| Plan type | Primary care doctor and referrals | Out-of-network care (not emergencies) |
|---|---|---|
| HMO | Usually pick a primary care doctor; referrals usually needed | Generally not covered |
| PPO | Referrals generally not needed | Covered, at a higher cost |
| EPO | Usually no primary care doctor or referrals needed | Not covered |
| POS | Usually pick a primary care doctor; referrals needed for specialists | Covered at a higher cost, often only with a referral |
The label doesn’t tell you how big the network is. As healthinsurance.org points out, any of the four types can have a broad, narrow or mid-size network. For a closer look at the other types, see PPO plans, EPO plans and PPO vs. HMO.
How common POS plans are
| Plan type | Employer plans: share of covered workers, 2026 | Marketplace: share of plans offered, 2026 |
|---|---|---|
| PPO | 50% | 15% |
| HMO | 12% (includes EPOs) | 46% |
| EPO | Counted with HMOs | 33% |
| POS | 8% | 7% |
In KFF’s 2025 survey, the POS share was 9%, but KFF changed how it groups plan types in 2026, so the two years don’t line up exactly. Either way, POS plans are a small slice of both markets. If you buy your own coverage, there may be no POS plan in your area at all, since about 8 in 10 Marketplace plans in 2026 were HMOs or EPOs.
Who a POS plan suits
A POS plan can work well if you like having one doctor coordinate your care and don’t mind asking for referrals, but you want some coverage if you ever decide to see a doctor outside the network. That might be a specialist you already trust who isn’t in network, or a second opinion from a provider in another system.
It’s a weaker fit if you want to book specialists directly without a referral, or if you expect to use out-of-network providers often. A PPO is built for that, though it may cost more. And if you’ll stay in network anyway, an HMO or EPO with the doctors you need may be simpler.
How to tell what kind of plan you’re looking at
The quickest way to check a plan’s type is its Summary of Benefits and Coverage (SBC), a standard summary you get when you shop for a plan, renew it or ask for one.
- Top of the first page: The “Plan Type” field shows HMO, PPO, EPO or POS.
- “Will you pay less if you use a network provider?”: This row explains in-network and out-of-network costs.
- “Do you need a referral to see a specialist?”: This row tells you whether the plan uses referrals.
Then check the plan’s provider directory for your own doctors. See how to find out if a doctor is covered by your insurance.
See which plan types are sold where you live: compare plans by ZIP code.
Frequently asked questions
Is a POS plan better than a PPO?
It depends on how you use care. A PPO lets you see specialists and out-of-network providers without referrals, while a POS plan usually routes care through your primary care doctor. Compare the two plans’ premiums, deductibles and networks side by side.
Do POS plans cover out-of-network care?
Yes, but at a higher cost, and many require a referral from your primary care doctor first. You may have to file the claim yourself and pay any amount above the plan’s allowed charge.
Do I need a referral with a POS plan?
Usually, yes. HealthCare.gov says POS plans require a referral from your primary care doctor to see a specialist. Check your plan’s SBC for its exact rules.
Can I buy a POS plan on the Marketplace?
Sometimes. About 7% of 2026 Marketplace plans were POS plans, so there may not be one where you live.
Sources
This article is general information, not insurance advice. Referral rules, out-of-network benefits and costs differ from plan to plan. Last reviewed October 2026.