Medical Expense✓ Verified · outline & fact-checked · Sep 2026Difficulty 1/5
A member of a Point-of-Service (POS) health plan wants to see a specialist who is outside the plan's network. Under the typical POS structure, what must the member do first?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
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.
Why the other options are wrong
- A) Going out of network without a referral is a PPO feature; a POS plan keeps the gatekeeper requirement even when the member leaves the network.
- C) A member does not have to leave the POS plan to use out-of-network benefits; out-of-network access with a referral is built into the POS design.
- D) CMS is the federal Medicare agency and plays no role in authorizing a privately insured POS member's specialist visit.
Memory hook
POS = PPO flexibility plus HMO gatekeeper. Want out-of-network care? Get the PCP's referral first.