Point of Service Plan (POS)
It’s important to understand that anytime you access the out-of-network benefit on the medical Point of Service (POS) plan, you will pay substantially more out-of-pocket. That is due to there not being any contractual agreement between the insurance carrier and the medical provider to offer services at a discounted rate.
When you seek services in-network, you are accessing physicians and facilities that have agreed to provide services per the provider network discounts outlined in their contracts with the insurance carriers. When you pay 10% for your services in-network on the medical POS plan, you are paying 10% of a contracted, discounted rate.
Below is an example of the difference between in-network and out-of-network services on the medical POS plan. Please keep in mind that this is just an example and does not reflect actualpricing of costs or services:
Aetna Medical POS Example: You are having a baby, normal delivery. We will assume the estimated charges considered to be usual, customary and reasonable for the hospital stay and routine obstetric care amount to $6,000.
In-Network:
Applied deductible: $0 (there is no annual deductible on this plan)
Your percentage of cost in-network: 10% which equals $600
Total estimated cost in-network for these services: $600
Out-of-network:
Applied deductible: $0 (there is no annual deductible on this plan)
Separate hospital deductible: $500
Your percentage of cost out-of-network: 50% which equals $3,000
Total estimated cost out-of-network for these services: $3,500
By choosing an out-of-network physician or hospital for the normal delivery of your baby, you pay $2,900 more than if you sought these services from an in-network physician and hospital.
There is really no reason to seek services out-of-network unless you already have a relationship with a particular trusted medical professional from whom you’ve received services in the past. Aetna has hundreds of physician choices, including specialists, in the greater Los Angeles area.
DENTAL POS Plan
When you seek services in-network, meaning, from dentists/providers listed in the EPO or PPO networks, you are paying less for services since these dentists/providers have agreed to provide services per the provider network discounts outlined in their contracts with the insurance carriers. When you pay 40% for major services in-network when seeking services from an EPO dentist, you are paying 40% of a contracted, discounted rate.
Below is an example of the difference between in-network and out-of-network services on the dental POS plan. Please keep in mind that this is just an example and does not reflect actualpricing of costs or services:
Principal Dental POS Example: You need a porcelain crown on a molar. We will assume the estimated charge considered to be usual, customary and reasonable is $800.
In-Network, EPO:
Applied Deductible: $0. No deductibles apply to any services accessed in the EPO network.
Your percentage of cost in the EPO network is 40%: You pay $320 or less. The EPO network discounts could be deeper, providing you with a lower out-of-pocket cost.
Total estimated cost in-network for the porcelain crown on a molar: $320
Out-of-Network: The out-of-network dentist decides to charge $1,000 for the porcelain crown on a molar. This dentist is not prohibited from charging what he/she feels can be charged for this service.
Applied deductible: $50
Your percentage of cost out-of-network is 40%, and usual, customary and reasonable is considered $800 for this service: You pay $320 AND, you owe the difference between the usual, customary and reasonable amount and what the out-of-network dentist decided to charge you ($1,000 – $800), which is an additional $200.
Total estimated cost out-of-network for the porcelain crown on a molar: $570
There is really no reason to seek services out-of-network unless you already have a relationship with a particular trusted dentist from whom you’ve received services in the past. Principal has a robust EPO and PPO network offering hundreds of dental choices in the greater Los Angeles area.