When a health care coverage plan is labeled as "open access" this means that plan members can choose their own doctors, including specialists, without a referral. However, just because plan participants are given a choice does not mean the costs will be covered. Sorting through choices in health care coverage involves learning the difference in basic group plans and what all the acronyms mean in the health insurance alphabet soup.
The health insurance industry uses several acronyms in referring to different coverage options. For example, an HMO, which stands for Health Maintenance Organization, covers members who use health care service providers and hospitals that have contracts with the particular HMO. Members pay a set monthly cost and copayments are typical. Except for emergency services, they generally cover nothing out of the network.
HMOs were the first type of managed health care plan, which generated other types. Often, managed health care plans refer to the member's PCP. PCP stands for primary care physician and is used synonymously with family doctor.
Preferred Provider Organizations
A PPO, or preferred provider organization, is a managed health care plan that uses a network of health service professionals and facilities to provide services to members at reduced costs. If plan members go outside the network, costs may not be reduced. For example, members can choose to see any doctor, an open access feature. However, the PPO will pay a larger percentage of the costs if the doctor is part of its preferred network.
A point-of-service plan is called simply a POS in health insurance jargon. This type of plan combines features of an HMO, a PPO and traditional health insurance. Members choose to allow their PCP to control all referrals so that costs are fully covered, or choose an out-of-network provider and take responsibility for part or all of the costs.
Open Access Choices
Open access works like traditional health insurance in that plan members have choices in what doctors to see and services to use, all of which may not be covered in a particular plan. In addition, both HMO and POS plans may offer open access features. For example, members can choose specialists without a referral from their PCP. However, the choice must be made from an approved directory of specialists or the member pays more of the associated cost.
Finding More Answers
The Agency for Healthcare Research and Quality, a federal government agency under the umbrella of the Department of Health and Human Services, offers consumers free and timely information on the latest changes in the health care industry. The site also offers expert advice from a licensed physician on how to navigate the health care system as well as information on comparing health care plans. Visit their website for more information.