What is an Open Access Health Plan?

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When an insurance provider refers to their health plans as having "open access," they refer to how you get control over which health providers you use. You often won't need a referral from your primary care provider to see other physicians and specialists, but you may need to choose a provider within the network to have coverage. You can find a variety of open access health plans that will vary based on provider options and costs for things such as monthly premiums, deductibles and copayments. You'll want to understand and compare the different open access plans available to you to find the one that works best for your health care needs.

Tip

An open access health plan frees you from needing to get referred to see doctors and surgeons besides your primary care provider. Your plan may limit this freedom to in-network providers or allow for those outside the network as well.

Open Access Health Plan Overview

Traditionally, insurance plans have you select a doctor who will provide your primary care and refer you to other providers when you need special care, treatments or procedures; the exception is usually for emergency care. Open access plans may make having a primary care provider optional to give you more freedom over your care, though some states and plans may still require you to have a primary care provider.

There are different tiers of OAP insurance that determine how much freedom you have in choosing medical professionals without a referral. For example, Cigna offers an Open Access Plus plan that supports both in-network and out-of-network providers with no referral needed, but its Open Access Plus In-Network plan doesn't cover out-of-network providers at all unless you have an emergency or receive permission from the insurer.

Even though you can seek care with a supported provider of your choice, note that your insurance company might still require a preauthorization for certain services, procedures or hospital visits. The insurance company usually handles this for you as long as you choose someone in the network. Otherwise, you might be asked to fill out some paperwork for care from an out-of-network provider.

How Open Access Plans Work

Besides the wider freedom that comes with not needing a referral, open access health care plans otherwise work like traditional insurance options. They may have an annual deductible that you must meet before certain benefits kick in, along with a maximum out-of-pocket amount after which all covered services would be paid in full by the insurer. You'll usually often have coinsurance where both you and the insurer are partly liable for the cost of covered care for certain services like surgeries, hospital visits and medical tests.

Visits to doctors and specialists, along with certain tests and procedures, often have a set copayment you're liable for when you check in at the office, and you may have to pay coinsurance as well. For example, you might pay a $25 copayment to see a specialist of your choice and then pay 20 percent of the cost of any tests, with your insurer paying the other 80 percent. Preventative care is typically free with no copayment or coinsurance, so you usually won't get a bill for an annual physical with basic screening tests.

Medications often have tiered prices depending on the type of drug such as a generic, name-brand or premium medication. A prescription deductible can also apply.

Types of OAP Insurance Plans

Health insurance companies offering open access benefits often offer a few different types of plans you can select. These include health maintenance organization, preferred provider organization and point-of-service plans. These differ mainly in how much you pay for things like premiums and deductibles and whether you must see in-network physicians.

  • HMO: Open access HMO plans require choosing your health providers from within the network nationwide except for when you need essential emergency treatment. So, if your preferred doctor doesn't participate and it's not an emergency, you'd likely end up shouldering the cost, making it a more limiting option. However, these plans often come with lower copayments, premiums and deductibles versus other options. In the case of certain plans like the Aetna Open Access HMO plan, you may pay no deductible at all.
  • PPO: This type of open access plan allows you to get help from providers within and outside the insurer's network but usually offers the best coverage when you choose an in-network provider. You usually don't need a referral from your primary care provider to see an out-of-network provider, but you can expect to pay more for services when you don't get in-network care. Deductibles and premiums tend to be higher than with HMO plans. This option is useful if you travel worldwide or just don't want to switch to an in-network physician.
  • POS: When comparing POS to PPO and HMO plans, you'll find this less common option is a sort of hybrid of the other two. This plan allows for in-network and out-of-network providers and has coverage on a tier like a PPO plan. POS plans usually doesn't require a deductible or referrals, and like HMO plans, it usually comes with low copayments. Premiums tend to fall in between those of HMO and PPO plans. However, this option can come with a lot of paperwork to send in your claims when you seek out-of-network coverage.

OAP Insurance Pros and Cons

The freedom you have to bypass needing a referral is the main benefit of an OAP health plan. This removes the hassle of meeting with your primary care provider before you can get specialist care. When you choose an open access PPO or POS plan, you get the benefit of having a wide level of coverage to see any provider you wish. You also get the assurance of emergency coverage with any of the open access plan types.

However, you face a limitation when you choose an open access HMO plan; while you might pay less in premiums and the deductible, you won't be able to see out-of-network doctors without the insurer making an exception for you. This can present a problem when the best specialist in your area falls outside your plan and would require you to pay out of pocket. When you opt for PPO and POS plans, you get that extra outside coverage but usually pay more and may have paperwork to handle for out-of-network services.

Choosing an OAP Health Plan

If your employer offers OAP insurance options, you'll want to consider your health situation, finances and preferences in deciding which plan to choose. Taking a look at costs for premiums, copayments, coinsurance, drug coverage and deductibles is a good place to start. Your insurer's website might have a cost calculator that can provide a better idea of how much you'd spend in total treating a certain health condition, having a child or using minimal benefits.

When comparing open access PPO vs. HMO options, check the insurance's network of providers to determine whether your preferred doctor is covered in the network. If so, you might save more money choosing an open access HMO plan than paying more for a PPO plan where you won't even take advantage of the out-of-network coverage. If an open source POS plan is available, the midrange premiums might be a good compromise if you think you might need out-of-network coverage and you don't mind the additional paperwork.

If you end up choosing a plan that has a high deductible, consider looking into whether a health savings account is available. This option would allow you to contribute some pretax money from your paycheck to a special savings account you can use to pay for medical costs like copayments and medication.

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