Defining Point of Service (POS) Health Insurance


 Defining Point of Service (POS) Health Insurance


One of the most confusing aspects of healthcare is understanding how insurance works. With health insurance, such as Point of Service (POS) health insurance, it can sometimes be difficult to decipher what you are paying for. Insurance is meant to help pay for medical bills and prevent you from having to pay out of your own pocket. But what exactly does POS health insurance cover?

In a nutshell, Point-of-Service Health Insurance covers a different set of benefits than other types of coverage. While traditional plans may cover you for a certain number of doctor visits or reimburse you a certain amount per visit, Point-of-Service plans give you the freedom to choose your own doctors under certain restrictions. With this type of insurance, you decide when to seek medical treatment and only have to pay a small deductible.

Your plan will also cover additional services that are not included in every other type of insurance such as vision and dental care, in addition to prescription copays. But these are all benefits where restrictions apply; for example, you may be required to choose providers within your network for these services. This is where your deductible comes into play; if you choose a provider outside of your network then the entire bill is left up to you. The HealthCare.Gov website has a table with the cost and/or coverage for each class of POS coverage under the Affordable Care Act (ACA). As long as you have enough family members in your plan, then you are eligible to receive assistance from a subsidy to help pay for your premiums.

So, what exactly can POS health insurance cover and what are some of the bills that it is not meant to cover? Below is a list of some of the most common questions about Point-of-Service Health Insurance.

What types of benefits does POS Health Insurance cover?
For patients who are covered by healthcare plans that contract with the HealthCare.Gov website, then you are eligible to receive help paying for your premiums, allowing you to receive healthcare coverage at a reduced price. Those who are eligible can receive up to a 72% discount on their monthly premiums.

If you have coverage under the Affordable Care Act (ACA), then you should be covered under Healthcare Essential Benefits. If more than 60% of the people in your household meet the income requirements and if they do not already have insurance, then they will be eligible for Medicaid or CHIP. Anyone who is older than 65 and qualifies for Medicare can also rely on POS health insurance to help cover additional costs such as prescriptions, dental care and vision.

With the way that Healthcare.Gov is designed, then any family with a member that is under 18 and lives in a household of four or less will qualify for the following:

With this plan, then you are entitled to the following benefits under POS Health Insurance:
If you need coverage for longer than two months but do not have it through your employer or through Medicaid, then you can still qualify for temporary coverage under your state. You may even be able to keep the same doctors in which case you would be granted an Interim Enrollment Period (IEP) which could last up to 90 days. If it is determined that you are eligible for Medicaid after your IEP has expired, then you can be placed on Medicaid retroactively as well.

If you are not covered under and if you have a child older than 18 years of age who is not enrolled in school, then you can qualify for K-12 Health coverage through Medicaid. This will allow you to receive benefits such as: 

The discount varies from state-to-state but it normally ranges to about 22% off of your monthly premium. For example, in Utah consumers will see a 36% discount; in Texas, the discount is 35% and in Washington State the cost is 33%. You would need to visit the state-specific HealthCare.Gov website in order to find out your individual state's coverage.

How does POS health insurance work?
With POS health insurance, the concept is that you are free to choose your own doctors. But certain restrictions apply: 
In a nutshell, you must be under the age of 65 and not eligible for Medicare or Medicaid at the time of enrollment. You must also be enrolled in one of the HIPAA plans which means that they are allowed to see your medical records and give you pre-authorization for services freely without contacting your doctor or referring you to one. You cannot be under the employ of an employer providing health insurance and you must also not qualify for any other types of coverage such as an HMO or PPO.

You are allowed to choose a primary care physician, specialist, hospital or any other provider that is within your network. You are allowed to choose up to five providers or more in order to maximize your coverage. You should be aware that the same group of providers may fall within two different networks. For example, if you have a primary care physician who is in the network at one practice but he works with another group of physicians for his specialists, then he may be able to see you after-hours even if he is not in your network for either primary care or specialists. It is up to you to read the fine print and figure out whether a particular provider is within your network or not.

If you choose a provider outside of your network, then all costs are up to you. You can expect that the costs will be higher for a provider outside of your network but it does not mean that you will always have to pay more than with an in-network provider. Most insurance providers just like other vendors often negotiate discounts with providers outside of their network and this can result in lower costs for the patient.

What are some common bills that POS health insurance does not cover?
Unlike traditional health insurance plans, POS does not cover regular yearly hospital stays in the case of an emergency. And unlike ACA, POS does not cover mental health visits and substance abuse services. It is also important to note that it does not cover prescription drugs except basic medications. And lastly,POS is NOT a replacement for your Medicare or Medicaid coverage.

Should I include my spouse and children under my POS coverage? If you already have family members who could benefit from the coverage then including them as well would be a good idea. Having more people covered under one insurance plan can lower your overall costs which will result in even lower premiums for everyone involved.

There are many people who need to have healthcare but cannot afford it. For this reason, the Affordable Care Act was created in order to help those who need help getting access to healthcare without having to compromise their own finances in the process. POS health insurance is one of the ways that this is achieved by spreading the costs around among millions of taxpayers and individuals with lower incomes. This type of coverage is ideal for those who do not qualify for Medicaid or Medicare and who do not have any other insurance through their employer. Getting insured under POS health insurance can save you money while still allowing you to see more than one doctor at a time which can result in better care and more personalized patient services as well.

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