Commission for Case Manager Certification (CCMC) Practice Exam

A defining feature of Point of Service (POS) plans is the requirement for a primary care physician to provide a referral for out-of-network services. In a POS plan, members typically choose a primary care physician who acts as a gatekeeper for accessing specialist services. If a member wishes to receive care outside of the network for which the plan is designed, they must first get a referral from their primary care physician. This process helps manage healthcare costs and ensures that patients receive necessary and appropriate care.

The structure of POS plans combines features of both Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). While members have flexibility regarding out-of-network options, they must adhere to this referral requirement to ensure coverage for those services. This system encourages coordinated care and continuity, as the primary care physician can make informed decisions based on the patient’s health needs and history.