PPO vs EPO

Obtain a referral from the primary care physician (gatekeeper) before seeing the out-of-network specialist — A POS plan is a managed care hybrid: like an HMO it requires the member to select a primary care physician who acts as a gatekeeper, and like a PPO it allows care outside the network. The tradeoff is that using an out-of-network specialist ordinarily requires a referral from the primary care physician, and out-of-network care carries higher cost-sharing. Because the gatekeeper-referral mechanism is preserved, the member must obtain that referral before the out-of-network visit.

National insurance concept

HMO-style gatekeeper coordination with PPO-style out-of-network coverage — A POS plan merges the two dominant managed care models: it uses an HMO-like primary care physician (PCP) who coordinates care and issues referrals within the network, while also permitting members to seek care from out-of-network providers, usually at a higher deductible and coinsurance level. The gatekeeper element keeps utilization and cost down, while the out-of-network option adds member flexibility. Under the examination outline for individual medical plans (AH-III.A.1a), POS plans are classified alongside HMO, PPO, and EPO as a distinct delivery type, so recognizing this hybrid structure is a tested point.

National insurance concept