Point Of Service

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Point Of Service

• Information about POS as a Health Care Insurance
  Provider

by Melissa Weisensee
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Point of Service?
What is POS?
Why should you consider POS as your health care
provider
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POS Advantages for Employers

• More predictable cost
• One plan, one risk pool
• One company administration
• Benefit plan enhancement

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POS Advantages for Employees

• More coverage
• Lower out of pocket costs
• Freedom to pick and choose doctors.

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Managed Care Spectrum
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POS in Policyholder Terms
POS offers a single risk pool and provider
choice for the employer along with many other
benefits
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POS in Provider Terms
POS emphasize the gatekeeper otherwise known
as the Primary care Physician
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POS in Carrier Terms
POS has been effective in curtailing costs
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Administrative Costs

• Network management-
• Communication and education
• Claims system is complex
• Out-of-network utilization

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Trade-off for High Costs
The tradeoff is that the reduction in medical
costs, proportionate to administrative costs, are
so great that tremendous savings can still be
delivered with Point-of-Service
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Size Requirements for POS

• Groups under 75 people POS is Not
  Available
• Groups with 75-200 people Standard POS is
  Available
• Groups Over 200 People Standard POS is
  Available along with many other
  administrative benefits

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Percentage Payable under a POS
In Network
Out of Network
80 to 100 in network is payable under a POS
50 to 80 out of network is payable under the
POS plan
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Routine Health Assessment under POS
In Network
Out-of Network
80-100 after co-pay Ages max
visits 2-5..........................
Yearly 6-20........................ Every other
year 21-40...................... Every 5
years 41-65...................... Every 3
years over 65................... Yearly
Out-of-Network NOT COVERED
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Point-of-Service I.D. Card
Front of Membership Card
Back of Membership Card
Member Eff Date Exp Date 13579024600
03/01/97 02/28/98 Jetson, George Group
004XX2 Birth Sex Tier Hood River MIL
01/01/40 M EMC P 930949612JLL Larson,
John L. PH [phone]
Benefit Description CO-PAY Primary Care
Doctor 10.00 Specialist Referred 15.00 Prescript
ion Drugs 5.00 Emergency Room 50.00 Inpatient
Hospital 100.00 Inpat Mental Health 30.00 Outpa
t Mental Health 15.00
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POS Payment Methodology
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Definitions to Know
These are some important definitions to know when
reviewing over a POS plan as an option

• Co-payments- a fixed dollar amount, for example,
  a 10 co-pay at the PCPs office. They are
  considered to be due at the time of service, and
  do not accumulate like a deductible
• Deductibles- are a common form of cost sharing.
  If used on the In-Network portion of this
  product, it must be paid before any other
  coverage applies
• Coinsurance- is also a common form of cost
  sharing that sets a percentage limitation on the
  amount of coverage
• Capitation- is a monthly payment per capita to
  the physician regardless of whether or not
  services are rendered

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The End
Any Questions e-mail me at weisense_at_creighton.edu
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Sources

• Mutual of Omaha Underwriting and Insurance Guide
  to Point-of-Service
• http//www.bcbsmd.com/51_/point.html
• http//www.bcbsutah.com/pos.html
• http//www.methealth.com/wwwboard/
  messages.html