POS and PPO plans both let you see doctors outside the plan’s network, which sets them apart from HMOs and EPOs. The difference is in how you get there. A POS plan works through a primary care doctor and referrals, while a PPO lets you book specialists directly.
Quick answer: A POS plan requires a primary care doctor and referrals to see specialists, but still pays something toward out-of-network care, usually with lower premiums than a PPO. A PPO costs more each month but lets you see any specialist without a referral and covers out-of-network care at a higher cost share. Choose a POS plan if you’re happy to coordinate care through one doctor; choose a PPO if you want to keep specific specialists or see providers outside the network often.
What Is POS vs PPO?
A POS (point of service) plan is a hybrid of an HMO and a PPO: you choose a primary care physician, need referrals for specialists, and get some out-of-network coverage at a higher cost. A PPO (preferred provider organization) plan has a network of preferred providers but lets you see any doctor, in or out of network, without a referral, paying more when you go outside the network.
How a POS plan works
• Primary care physician (PCP): you pick a PCP from the network, who coordinates your care.
• Referrals: HealthCare.gov’s definition is that POS plans require a referral from your primary care doctor to see a specialist.
• In-network care: usually the lowest cost, often with copays and a lower deductible.
• Out-of-network care: covered, but usually with a separate, higher deductible and coinsurance, and sometimes only with a referral. You may also have to file the claim yourself.
Insure Omni’s guide to the POS health plan covers the basics in more detail.
How a PPO plan works
• No PCP requirement: you can choose a primary care doctor, but you don’t have to.
• No referrals: you can book a specialist directly. HealthCare.gov notes that you can use providers outside the network without a referral, for an additional cost.
• In-network care: lower cost through the plan’s negotiated rates.
• Out-of-network care: covered at a higher cost share, and the provider may bill you for the difference between their charge and what the plan allows.
PPOs are the most common plan type in employer coverage. In KFF’s 2025 Employer Health Benefits Survey, 46% of covered workers were in a PPO and 9% were in a POS plan.
Key POS vs PPO differences
| Feature | POS plan | PPO plan |
| Primary care physician | Required | Optional |
| Referrals to see specialists | Required | Not required |
| Out-of-network coverage | Yes, at higher cost; may need a referral | Yes, at higher cost; no referral |
| Monthly premiums | Usually lower than a PPO | Usually higher |
| Paperwork | Referrals, and you may file out-of-network claims | Less for specialists; you may file out-of-network claims |
| Best for | People who want lower costs and are fine with a care coordinator | People who want direct access to specialists |
What is a disadvantage of a POS plan?
The main disadvantage of a POS plan is the referral step. You need your PCP’s approval to see a specialist, which can add time and an extra appointment. Out-of-network care also tends to cost much more than in-network care, may need a referral to be covered at all, and may require you to pay upfront and file the claim yourself.
HMO vs PPO vs EPO vs POS
The four main health insurance plan types differ in two ways: whether you need referrals, and whether out-of-network care is covered. HMOs and EPOs generally cover only in-network care except emergencies, while POS and PPO plans pay something toward out-of-network care.
The four plan types in brief
• HMO (health maintenance organization): usually covers care only from doctors who work for or contract with the HMO, and generally won’t cover out-of-network care except in an emergency. Most HMOs require a PCP and referrals. See Insure Omni’s guide to the HMO plan.
• EPO (exclusive provider organization): covers services only from in-network doctors, specialists, and hospitals, except in an emergency. Many EPOs don’t require referrals. See what an EPO health plan is.
• POS (point of service): lower costs in network, a PCP, referrals for specialists, and some out-of-network coverage.
• PPO (preferred provider organization): lower costs in network, no referrals, and out-of-network coverage at an additional cost.
Full comparison
| Feature | HMO | EPO | POS | PPO |
| PCP required | Usually | Often not | Yes | No |
| Referrals for specialists | Usually | Often not | Yes | No |
| Out-of-network coverage | Emergencies only | Emergencies only | Yes, at higher cost | Yes, at higher cost |
| Typical premium level | Lower | Lower to moderate | Moderate | Higher |
| Flexibility | Lowest | Moderate | Moderate | Highest |
| Best for | Lowest cost, happy with one network | Direct specialist access within a network | Lower cost with an out-of-network backup | Keeping specific doctors, frequent out-of-network care |
Premium levels are general patterns, not rules. In any given area, an HMO from one insurer may cost more than a PPO from another, so always compare actual quotes. Insure Omni’s overview of the 7 types of health insurance plans also covers high-deductible plans, and HDHP vs PPO compares those two directly.
Which plan type fits you?
Do you need to keep a doctor who is out of network?
├── Yes → PPO (or POS if you’re happy to use referrals)
└── No → Do you want to see specialists without a referral?
├── Yes → EPO or PPO
└── No → Is the lowest premium your priority?
├── Yes → HMO
└── No → POS, for an out-of-network backup
Note: Plan rules vary. Some HMOs don’t require referrals, some EPOs do, and some plans called PPOs have narrow networks. Check the plan’s Summary of Benefits and Coverage before you enroll.
POS vs PPO Costs: Premiums, Deductibles, and Out-of-Pocket Math
PPO plans usually have higher premiums than POS plans, in exchange for more freedom. Your total cost for the year depends on premiums plus what you pay when you use care: deductibles, copays, coinsurance, and anything out of network.
What the premium data shows
In KFF’s 2025 Employer Health Benefits Survey, the average annual premium for employer coverage was:
| Coverage | All plans | PPO plans |
| Single | $9,325 | $9,818 |
| Family | $26,993 | $28,272 |
These totals include the employer’s share. KFF also reported an average general deductible of $1,886 for workers with single coverage. Individual plans bought on the ACA Marketplace are priced differently, by age, location, and metal tier.
How cost sharing works
• Premium: what you pay each month to keep coverage.
• Deductible: what you pay for covered care before the plan starts sharing costs. POS and PPO plans often have a separate, higher deductible for out-of-network care.
• Copay: a flat amount for a visit or prescription.
• Coinsurance: your percentage of the cost after the deductible. A common pattern is 80/20 in network (the plan pays 80%, you pay 20%) and 60/40 or 50/50 out of network, though plans vary.
• Out-of-pocket maximum: the most you’ll pay for covered in-network care in a year. Out-of-network care may have a separate, higher limit, or none at all.
Out-of-network cost example
Here’s a hypothetical example of a $10,000 out-of-network surgery bill, where the plan’s allowed amount is $6,000. The deductibles and coinsurance are illustrations, not real plan terms.
| POS out of network | PPO out of network | PPO in network | |
| Provider’s bill | $10,000 | $10,000 | $6,000 (negotiated rate) |
| Plan’s allowed amount | $6,000 | $6,000 | $6,000 |
| Deductible | $4,000 | $3,000 | $1,500 |
| Your coinsurance on the rest | 50% of $2,000 = $1,000 | 40% of $3,000 = $1,200 | 20% of $4,500 = $900 |
| Plan pays | $1,000 | $1,800 | $3,600 |
| Possible balance bill | $4,000 | $4,000 | $0 |
| You pay in total | Up to $9,000 | Up to $8,200 | $2,400 |
The key point is the balance bill: an out-of-network provider can often charge you the difference between their price and the allowed amount, and that difference usually doesn’t count toward your out-of-pocket maximum. Staying in network is by far the cheapest option on either plan.
Total annual cost by healthcare use
This hypothetical example assumes premiums of $450 a month for a POS plan and $550 for a PPO, all in-network care, a POS deductible of $1,000 and out-of-pocket maximum of $6,000, a PPO deductible of $1,500 and out-of-pocket maximum of $5,000, office visit copays of $30 (POS) and $40 (PPO), and 20% coinsurance after the deductible.
| Healthcare use | POS total for the year | PPO total for the year |
| Low: two office visits | $5,460 | $6,680 |
| Moderate: $3,000 of covered care | $6,800 | $8,400 |
| High: reaches the out-of-pocket maximum | $11,400 | $11,600 |
In this example, the POS plan costs less at every level of use, as long as you stay in network. The PPO’s advantage shows up when you see out-of-network providers or want to skip referrals.
Balance Billing and the No Surprises Act
Balance billing is when an out-of-network provider bills you for the difference between their full charge and what your plan pays. The federal No Surprises Act, in effect since January 1, 2022, protects you from surprise balance bills in specific situations, but not when you knowingly choose an out-of-network provider for planned care.
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When you’re protected
According to CMS, the No Surprises Act protects you from unexpected out-of-network bills for:
• Emergency care: including emergency room visits at out-of-network hospitals
• Non-emergency care at in-network facilities: for example, an out-of-network anesthesiologist or radiologist at an in-network hospital, hospital outpatient department, or ambulatory surgical center
• Air ambulance services: from out-of-network providers
In these cases, you generally pay only your plan’s in-network cost sharing.
When you’re not protected
If you choose to see an out-of-network doctor for planned care, which is the main reason people pick a POS or PPO plan, balance billing can still apply. In some cases a provider can ask you to sign a notice giving up your protections for certain non-emergency services. Read anything you’re asked to sign before a procedure.
How POS and PPO plans handle out-of-network claims
• Filing claims: in-network providers bill the plan directly. Out-of-network providers may ask you to pay upfront and then file the claim yourself for reimbursement.
• Referrals on a POS plan: some POS plans cover out-of-network specialist care at the better rate only with a referral, and others cover it at the out-of-network rate without one. Check your plan’s rules.
• Allowed amounts: both plan types pay based on an allowed amount, which can be well below what an out-of-network provider charges.
Note: Before planned out-of-network care, ask the provider for a written estimate and call your plan to ask what it will allow for that service. The gap between the two numbers is roughly what you may owe on top of your deductible and coinsurance.
Medicare Advantage HMO-POS vs PPO
In Medicare Advantage, an HMO-POS is an HMO plan that also covers some out-of-network services, usually at a higher copay or coinsurance. A Medicare Advantage PPO covers both in-network and out-of-network care without a PCP or referrals, typically with higher costs for out-of-network visits.
How Medicare Advantage HMO-POS plans work
According to Medicare.gov, members of Medicare Advantage HMOs generally must use in-network doctors and hospitals, with exceptions for emergency care, out-of-area urgent care, and temporary out-of-area dialysis. HMO-POS plans may also cover some out-of-network services, though you’ll usually pay a higher copayment or coinsurance. Most HMOs require you to choose a primary care doctor and get referrals for most specialist visits.
Medicare Interactive, run by the Medicare Rights Center, adds that plans with a POS option must still limit your out-of-pocket costs, and that POS visits to out-of-network providers generally don’t need a referral or prior approval. Which services qualify for the POS benefit differs from plan to plan.
Can you go out-of-network with an HMO POS?
Yes, for the services the plan’s POS benefit covers. You’ll usually pay more than you would in network, and the plan may cap how much it pays toward out-of-network care. Emergency and urgent care are covered out of network on any Medicare Advantage plan. For everything else, check the plan’s Evidence of Coverage to see which out-of-network services the POS benefit includes.
HMO-POS vs PPO for Medicare
| Feature | Medicare Advantage HMO-POS | Medicare Advantage PPO |
| Primary care doctor | Usually required | Not required |
| Specialist referrals | Usually required for in-network specialists | Not required |
| Out-of-network care | Some services, at higher cost | Covered, at higher cost |
| Emergencies and urgent care | Covered anywhere | Covered anywhere |
| Travel within the US | Limited to what the POS benefit covers, plus emergencies | Easier, since out-of-network care is covered |
| Typical premium | Often lower | Often higher |
| Best for | Seniors who want low costs and some out-of-network backup | Seniors who travel, split time between states, or want specific doctors |
Medicare Advantage plans differ widely in their rules and costs, even within the same plan type. Compare plans for your area in the Medicare Plan Finder on Medicare.gov.
Note: Medicare’s annual enrollment period runs from October 15 to December 7 each year, when you can switch Medicare Advantage plans or move between Original Medicare and Medicare Advantage for coverage starting January 1.
Do Doctors Prefer HMO or PPO Plans?
There’s no single answer. Doctors’ views depend on how each plan pays them and how much paperwork it creates. Some practices prefer PPOs because they involve fewer referrals and approvals, while others value HMO arrangements that bring a steady base of patients. What matters most for you is whether your own doctors are in the plan’s network.
How plans pay doctors
Health plans pay providers in different ways, and the arrangement can vary even within one plan:
• Fee-for-service: the plan pays a negotiated rate for each visit, test, or procedure. This is common in PPO networks.
• Capitation: the plan pays a set amount per member per month to a provider group, whatever care each member uses. This is more common in some HMO arrangements.
• Value-based or shared-savings arrangements: payment is partly tied to quality and cost targets.
Why some doctors are cautious about managed plans
The paperwork that comes with HMO and POS plans, especially referrals and prior authorization, is a common complaint among physicians. The American Medical Association has repeatedly raised concerns about the time and care delays associated with prior authorization. PPO plans can also require prior authorization for some services, but usually not referrals.
Do doctors prefer HMO or PPO for Medicare?
For Medicare, the question is often less about HMO vs. PPO and more about Original Medicare vs. Medicare Advantage. Many doctors accept Original Medicare, while Medicare Advantage plans each have their own networks, which a practice may or may not join. Some doctors join Medicare Advantage PPO networks but not HMO networks, or the other way round, depending on payment terms and administrative requirements.
What this means for you
• Before choosing a plan, check that your doctors are in its network for the coming year, not just this year.
• Call the doctor’s office as well as checking the plan’s directory, since directories aren’t always current.
• If you see several specialists, a PPO or Medicare Advantage PPO may make it easier to keep them.
Note: A doctor accepting a plan type doesn’t mean they accept every plan of that type. A practice may be in one insurer’s PPO network and not another’s.
How to Choose Between a POS and PPO Plan
Start with your doctors, then think about travel and how much care you expect to use, and finally compare the total yearly cost, not just the premium. That order answers the POS vs PPO question for most people.
Step 1: List your doctors, specialists, and medications
Write down every doctor and specialist you want to keep and every prescription you take. For each plan, check:
• Whether each doctor is in network
• Whether your medications are on the plan’s drug list (formulary), and at what tier
• Whether your preferred hospital is in network
If a doctor you rely on is out of network, a PPO usually gives you the simplest way to keep seeing them.
Step 2: Think about travel and out-of-state care
If you travel often, have children at college in another state, or split time between two homes, check how each plan covers care away from home. Some networks are regional, and out-of-network coverage on a POS plan may be limited. A PPO with a broad network is often easier for frequent travelers.
Step 3: Estimate your yearly healthcare use
Think about last year: how many doctor visits, specialist visits, tests, and prescriptions did you have? Are you expecting a baby, a surgery, or ongoing treatment? Higher expected use makes the deductible and out-of-pocket maximum more important than the premium.
Step 4: Compare total cost, not just premiums
For each plan, add up:
Total yearly cost = (Monthly premium × 12) + expected deductible + copays + coinsurance
Worst case = (Monthly premium × 12) + out-of-pocket maximum
If you’re buying individual coverage, check whether you qualify for premium tax credits, which can change which plan is cheapest. Insure Omni explains ACA subsidized plans, individual health plans, family health plans, and options for the self-employed.
Step 5: Read the Summary of Benefits and Coverage
Every plan must provide a Summary of Benefits and Coverage. It shows the deductible, out-of-pocket maximum, copays, coinsurance, and whether referrals are needed, in a standard format that makes plans easier to compare side by side.
Note: Open enrollment dates differ by type of coverage. Employers set their own enrollment windows, ACA Marketplace dates are published on HealthCare.gov, and Medicare’s annual enrollment period runs October 15 to December 7.
Conclusion
POS vs PPO comes down to a trade between cost and freedom. A POS plan usually costs less and keeps an out-of-network backup, but you work through a primary care doctor and referrals. A PPO costs more but lets you see specialists directly and use out-of-network providers more easily. Whichever you choose, staying in network keeps costs lowest.
| Your situation | Usually the better fit |
| Healthy, few doctor visits, want lower premiums | POS (or HMO) |
| Happy to have one doctor coordinate your care | POS |
| Need to keep a specific out-of-network specialist | PPO |
| See several specialists regularly | PPO |
| Travel often or split time between states | PPO |
| On Medicare, want low costs with some flexibility | Medicare Advantage HMO-POS |
| On Medicare, travel or want specific doctors | Medicare Advantage PPO |
Compare Health Plans With Insure Omni
If you’re shopping for individual or family coverage, Insure Omni can help you compare ACA health plans, including network type, deductibles, and out-of-pocket limits. Explore ACA health insurance at Insure Omni, or contact Insure Omni at 855-994-4151 to talk with a licensed agent.
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FAQS
The biggest disadvantage of a POS plan is that you need a referral from your primary care doctor to see a specialist, which can add an extra appointment and some delay. Out-of-network care also usually comes with a higher deductible and coinsurance, may be limited without a referral, and can mean paying upfront and filing the claim yourself. Out-of-network providers may also balance bill you.
POS plans require a referral from your primary care doctor to see a specialist, according to HealthCare.gov. PPO plans don't: you can see specialists, in or out of network, without a referral, though you'll pay more out of network. Both plan types may still require prior authorization for certain services, such as some surgeries or imaging.
There's no universal preference. Some doctors favor PPO arrangements because they involve fewer referrals and approvals, while others work closely with HMO networks. Each Medicare Advantage plan has its own network, so the key question is whether your own doctors are in the specific plan you're considering for next year.
Yes, for the services covered by the plan's point-of-service benefit, usually at a higher copay or coinsurance. Medicare.gov notes that HMO-POS plans may cover some out-of-network services, and every Medicare Advantage plan covers emergency and urgent care out of network. Check the plan's Evidence of Coverage to see exactly which out-of-network services are included and any annual limits.
Neither is better for everyone. A POS plan is usually the better value if you're comfortable using a primary care doctor and staying mostly in network. A PPO is usually better if you want to see specialists without referrals, keep an out-of-network doctor, or travel often. Compare the total yearly cost, including premiums and the out-of-pocket maximum, for your expected use.
Sources and 2026 Verification
- HealthCare.gov: Health insurance plan and network types
- KFF: 2025 Employer Health Benefits Survey
- Medicare.gov: Health Maintenance Organization (HMO) plans
- Medicare Interactive: Medicare HMOs
- CMS: No Surprises Act consumer protections
Disclaimer: Cost examples, deductibles, coinsurance rates, and premiums in this article are hypothetical illustrations unless a source is named. Plan rules, networks, and costs vary by insurer, state, and plan year. Always check a plan’s Summary of Benefits and Coverage or Evidence of Coverage before enrolling. This article is general information, not legal, tax, or medical advice.
