US · guidance
CMS Pub. 100-16, ch. 4, § 110.3
Health Maintenance Organization (HMO) and HMO Point of
Service (POS) Coverage and Access
(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)
HMOs restrict the network of providers from which a beneficiary can receive non-urgent/emergent covered services. HMOs furnish in-network services only.
To ease restrictions on access to out-of-network providers, however, an HMO may offer
a point of service (POS) benefit option. The following rules apply to an HMOPOS:
• Enrollees are allowed the option of receiving specified services outside of the
plan's provider network;
• An HMOPOS may require enrollees to incur increased cost-sharing for POS
services;
• An HMOPOS benefit option may limit out-of-network coverage to a specific
service or services, and may also limit the dollar amount of coverage that will be
provided; and
• The HMOPOS option may be offered as a mandatory supplemental benefit or as
an optional supplemental benefit.
For more information about the POS benefit option for an HMO, see section 30.3 above.
History
(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
1e6f047c08d1c602616b78cbcf930a816792f8f847247b0df3c7c00f8f8ffd9f
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