Point-of-Service Benefit

IN-NETWORK: Members generally receive health care from one of the Plan’s contracted network providers—the doctors, health care providers, hospitals, and durable medical equipment (DME) vendors who have agreed to take care of our members at negotiated rates. This care is provided at no or very low costs to members with no deductibles.

 

POINT-OF-SERVICE (POS): This benefit allows you the flexibility to choose to see an out-of-network (TRICARE®-authorized) provider when the service is available from an in-network provider. You will incur higher costs if you use the Point-of-Service option (see details below). While this benefit can give you greater freedom, you should be sure you understand what your out-of-pocket costs will be before you use this option. If you use your POS benefit, you do not need a referral from your primary care provider (PCP). We still strongly encourage you to have your PCP give you a referral, as they know your health the best and can help you choose the best specialist for your care.

IMPORTANT NOTE: When services are not available from an in-network provider and you are referred out of network, the referring provider may request an authorization for services to be covered at the in-network benefit level.

• During the authorization process, the plan will review medical criteria and policies to determine which benefit level is appropriate.
• f it is determined that the referred services are available from an in-network rovider, your authorization request to see an out-of-network provider may be approved, but it will be at the Point-of-Service (more costly) benefit level.

When you use the Point-of-Service option to get care outside of the US Family Health Plan network, you will pay a deductible of $300 per year for an individual or $600 per year for a family for outpatient services, and a cost share for inpatient and outpatient services of 50% of the TRICARE Maximum-Allowable Charge (TMAC). In addition, you may be subject to “balance billing” by the provider. You will be responsible for paying these bills, which may be amounts up to 115% of the TMAC. Any amounts paid for services received through the Point-of-Service benefit are NOT applied to your “catastrophic cap,” which means there is no maximum limit to these charges. If the provider you want to see does not participate with Medicare or TRICARE, you might be responsible for the entire bill.

Some members desire to seek health care outside of our network, even though an in-network provider is available to deliver this care. This option may provide some coverage for them to do so.

You may. Some health care services, such as knee replacement surgery, require authorization by Martin’s Point in order to be covered. When in doubt, you should always call Member Services to check.

The Point-of-Service benefit does not apply to:

• Care received by newborns and adopted children through the conditional 90 days or the effective date of enrollment, whichever is earlier
• Urgent and emergency care
• Radiology
• Pathology
• Anesthesiology, while inpatient
• If you have other health insurance
• Care being sought is not a TRICARE benefit or is determined not to be medically necessary

Additionally, Zostavax vaccine, non-emergent ambulance, diagnostic services, dialysis, diagnostic drugs, and sleep studies are not subject to POS.

This is not a comprehensive list; depending on billing, there may be other services that may or may not be covered under your POS benefit. 

Please call Member Services at 1-888-674-8734 to discuss specific questions you may have about the Point-of-Service option.