A point-of-service plan is the compromise candidate on an open enrollment menu. It borrows the gatekeeper from an HMO and the out-of-network tier from a PPO, and the sales pitch is that you get the best of both. What you actually get is a plan with two ways to be denied instead of one.
All figures below were checked on September 6, 2026. Employer numbers come from the 2025 KFF Employer Health Benefits Survey, the only national survey that measures POS plans separately from HMOs and PPOs. Marketplace numbers come from our own tabulation of the CMS 2026 Marketplace Plan Attributes and Rate Public Use Files, covering 4,044 standard on-exchange individual medical plans across the 30 HealthCare.gov states, cross-checked against the 2025 files.
What Is a POS Plan?
HealthCare.gov defines a point of service plan as one where “you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network,” and adds that “POS plans also require you to get a referral from your primary care doctor in order to see a specialist.”
KFF uses the same two-part test in its employer survey: a POS is a plan “with lower cost sharing for in-network services, but that requires a primary care gatekeeper for specialist or hospital visits.” Its PPO definition is identical minus the gatekeeper, and its HMO definition is a plan “that does not cover nonemergency services provided out of network.”
So the taxonomy is clean on paper. Two switches, four plan types.
POS vs PPO vs HMO: The Two Switches
| Plan type | Covers out-of-network care? | Referral to see a specialist? |
|---|---|---|
| PPO | Yes, at a worse tier | No |
| POS | Yes, at a worse tier | Usually |
| EPO | No, emergency only | No |
| HMO | No, emergency only | Usually |
That grid is how the Washington State Office of the Insurance Commissioner lays it out for consumers, and it matches HealthCare.gov’s own plan-type page. For the full head-to-head on the two mainstream options, see HMO vs PPO; for the no-out-of-network cousin, see EPO vs PPO.
One label that does not belong on this grid is HDHP. That is an IRS tax category about deductible size, not a network design, and a POS plan can also be an HDHP. HDHP vs PPO covers that separately.
What a POS Plan Costs, Measured
Here is where POS stops looking like a compromise. These are 2025 averages for covered workers, weighted, from Figures 6.6, 7.1 and 7.6 of the KFF Employer Health Benefits Survey.
| 2025 employer coverage | HMO | POS | PPO | All plans |
|---|---|---|---|---|
| Total premium, single | $9,229 | $9,377 | $9,818 | $9,325 |
| Total premium, family | $27,277 | $25,692 | $28,272 | $26,993 |
| Worker contribution, single | $1,299 | $1,513 | $1,514 | $1,440 |
| Worker contribution, family | $7,680 | $8,444 | $7,075 | $6,850 |
| Average deductible, single | $1,649 | $2,122 | $1,337 | $1,886 |
| Share with no deductible at all | 47% | 14% | 12% | 12% |
| Share of covered workers | 12% | 9% | 46% | n/a |
Three things jump out.
The POS family premium is the cheapest of the three, but the worker pays the most of it. At $25,692 the total POS family premium is $2,580 below the PPO. Yet the POS worker’s share is $8,444 against the PPO worker’s $7,075, and against a $6,850 all-plan average. The employer is picking up less. That is the number that hits your paycheck.
The POS deductible is the highest of the three non-HDHP types. $2,122 for single coverage, 59% above the $1,337 PPO figure. On aggregate family deductibles the gap is similar, $4,842 for POS against $3,118 for PPO.
POS is a small-employer product. 19% of covered workers at firms with 10 to 199 workers are in one, against 6% at firms with 200 or more.
One methodology caveat you should know before quoting these figures anywhere. KFF treats HDHP plans as their own category “even if the plan would otherwise be considered a PPO, HMO, POS plan, or indemnity plan.” So the POS row above is a non-HDHP POS row, and the same is true of the PPO and HMO rows. The comparison is fair between the three, but it is not a complete census of every POS plan sold.
The Referral Trap
This is the part that costs people real money, and it is not the same failure mode as “you pay more out of network.”
The NAIC, the association of state insurance regulators, puts it plainly: “Some health plans, like Point of Service (POS) plans, require referrals to see specialists,” and “in some instances, if you don’t get a referral before receiving care, the plan may not pay any of the costs of the services.”
Read that carefully. When a required referral is missing, the plan does not fall back to the out-of-network tier. It can deny the claim outright. You bought a plan with out-of-network coverage and then failed to unlock it, so you are paying the full billed charge with nothing applied to either deductible.
And even when the referral is in place, the out-of-network tier is punishing. Our tabulation of the CMS 2026 marketplace data found:
| 2026 marketplace POS plans | Figure |
|---|---|
| Plans requiring a specialist referral | 60% |
| Plans publishing an out-of-network deductible | 98% (410 of 417) |
| Median in-network deductible | $3,500 |
| Median out-of-network deductible | $15,000 |
| Plans publishing a dollar out-of-network out-of-pocket maximum | 34% |
| Median out-of-network out-of-pocket maximum where published | $26,700 |
| Median monthly premium, age 40, non-tobacco | $732 |
The out-of-network deductible is 4.3 times the in-network one. Two thirds of these plans do not publish any dollar cap on out-of-network spending at all, which means the ACA out-of-pocket maximum does not apply out there. HealthCare.gov’s own definition of that limit excludes out-of-network care and any charge above the allowed amount.
There is a real cross-source disagreement here worth flagging. HealthCare.gov states flatly that POS plans require a referral. CMS’s own plan-attributes data for those same 2026 marketplace plans records 40% of POS plans answering “no” to the specialist referral question, and 37% answered no in the 2025 files. Do not assume either way. Open the Summary of Benefits and Coverage for your specific plan and read the referral line.
If a claim is denied for a missing referral, you get an internal appeal and then an independent external review. Ask the specialist’s office whether a retroactive referral is possible, because in many plans it is, and appeal in writing before you pay anything.
What a POS Plan Means If You Pay Cash
For anyone who ends up paying the bill themselves, the POS design has one specific consequence: it is very easy to land in the worst-of-both-worlds cell without meaning to.
Go out of network with a referral and you face a median $15,000 deductible before the plan pays anything, plus coinsurance, plus a balance bill for whatever the provider charges above the allowed amount. Go out of network without the referral and you may get nothing at all. In both cases you are functionally a self-pay patient, but only in the second case does the provider still think you have coverage.
That distinction matters because the cash price and the out-of-network billed charge are usually different numbers, and the cash price is almost always lower. Three moves:
Ask for the self-pay rate before the visit. Once a claim has been submitted and denied, many offices will no longer honor their posted cash rate. See self-pay vs health insurance for when this trade is worth making deliberately.
Compare against posted prices. Hospitals must publish machine-readable standard charges including discounted cash prices. That is how you check whether a self-pay quote is fair. See hospital price transparency.
Negotiate anything already billed at gross charges. A denied out-of-network claim leaves you facing the chargemaster number, which is the single most negotiable figure in American healthcare. Start with how to negotiate medical bills.
It also pays to know the routine numbers so you can spot a bad quote. Compare against doctor visit cost without insurance, and if the referral system is what you are trying to escape entirely, direct primary care removes the gatekeeper by removing the claim.
The Bottom Line
Pick a POS when your employer’s version is genuinely cheaper on the paycheck line, your doctors are in network, and you are comfortable routing specialist visits through a primary care physician. Check the worker contribution, not the total premium, because the 2025 data shows those two can point in opposite directions.
Skip it when you self-refer often, when you travel, or when the out-of-network benefit is the reason you are considering it at all. A $15,000 out-of-network deductible that a missing referral can void is not much of a safety net. If the network itself is the constraint, read in-network vs out-of-network and what is a PPO plan before you decide, and check health insurance deductible so you are comparing the right line on each plan summary.