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What is an Open Access Health Plan?

When an insurance provider refers to their health plans as having “open access,” they refer to how you have control over which medical provider you use. You don’t usually need a referral from your primary care provider to see other doctors and specialists, but you may need to choose an in-network provider to get coverage. You can find a variety of open access health plans based on provider options and costs for things like 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 best suits your healthcare needs.

What is an Open Access Health Plan?
What is an Open Access Health Plan?

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An open access health plan saves you from having to be referred to doctors and surgeons next to your primary care provider. Your plan may limit this freedom to in-network providers or allow those outside the network as well.

Open Access Health Plan Overview

Traditionally, insurance plans allow you to choose a doctor who will provide primary care for you and refer you to other providers when you need special care, treatment, or procedures; exceptions are usually for urgent care. Open access plans can make having a primary care provider optional to give you more freedom in your care, though some states and programs may still require you to have a primary care provider.

There are different levels of OAP coverage that determine how much freedom you have in selecting medical professionals without a referral. For example, Cigna offers an Open Access Plus plan that supports both in-network and out-of-network providers without a referral, but its Open Access Plus In-Network plan does not include providers outside the network at all unless you have an emergency or get permission from an insurance company.
While you may seek care with a supported provider of your choice, note that your insurance company may still require prior authorization for certain services, procedures, or hospital visits. The insurance company usually deals with this for you as long as you choose someone in the network. Otherwise, you may be asked to fill out some paperwork to get care from an out-of-network provider.

How open access plans work

Besides the broader freedom that comes with not needing a referral, open-access health care plans would otherwise work like traditional insurance options. They may have an annual deductible that you must meet before certain benefits take effect, along with the maximum out-of-pocket amount after which all covered services will be paid for in full by the insurance company. Typically, you will have a coinsurance in which both you and the insurance company incur a portion of the cost of care covered for certain services such as surgeries, hospital visits, and medical tests.

Visits with doctors and specialists, along with certain tests and procedures, usually have a certain copay that you are subject to on an in-office examination, and you may also have to pay coinsurance. For example, you can pay a $25 copay to see a specialist of your choice and then pay 20 percent of the cost of any test, with your insurance company paying the remaining 80 percent. Preventive care is usually free without copays or coinsurance, so you usually won’t get billed for an annual health checkup with basic screening tests.
Drugs usually have prices depending on the drug such as generic, brand name or premium drugs. A prescription deduction may also apply.

Types of OAP insurance plans

Health insurance companies that offer open access benefits often offer several different types of plans you can choose from. These include health maintenance organizations, priority provider organizations, and point-of-service plans. These mostly vary in how much you pay for things like premiums and deductibles and whether you have to see an in-network doctor.
HMO: Open Access HMO programs require selecting your medical providers from within the nationwide network except when you need urgently needed treatment. So if your preferred doctor isn’t involved and it’s not an emergency, you’ll likely have to reduce costs, making it a more limited option. However, these plans often come with lower copays, premiums, and deductibles than other options. In the case of certain packages such as the Aetna Open Access HMO package, you may not have to pay any deductions.

PPO: This type of open access plan allows you to get help from providers inside and outside the insurance company’s network but usually provides the best coverage when you choose an in-network provider. You typically don’t need a referral from your primary care provider to see an out-of-network provider, but you may have to pay more for services when you are not receiving in-network care. Deductibles and premiums tend to be higher than HMO plans. This option is useful if you travel around the world or just do not want to turn to an in-network doctor.
POS: When comparing POS to PPO and HMO plans, you’ll find this less common option is a kind of combination of the other two. This program allows in-network and out-of-network providers and has coverage on a level like a PPO plan.¬†However, this option may come with plenty of paperwork to submit your request when you search for out-of-network coverage.

Pros and Cons of OAP Insurance

You are free to ignore the need for a referral as the main benefit of the OAP health plan. This removes the hassle of seeing your primary care provider before you can get specialized care. When you choose an open access PPO or POS plan, you’ll get the benefit of having ample coverage to meet any provider you want. You also get a guarantee of emergency insurance with any type of open access plan.

However, you face a limitation when choosing an open access HMO plan; while you may pay less than premiums and deductibles, you won’t be able to see out-of-system doctors if the insurance company makes an exception for you. This can cause problems when the best specialist in your area is not out of your plans and requires you to pay out of pocket. When you choose PPO and POS plans, you’ll get that extra external 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 coverage options, you’ll want to look at your health, financial situation, and preferences to decide which plan to choose. Considering the costs for premiums, copayments, coinsurance, drug coverage, and deductibles is a good place to start. Your insurance company’s website may have a cost calculator that can provide a better idea of how much you spend treating a certain health condition, having a baby, or using minimal benefits.
When comparing open access PPO and HMO options, check your insurance’s network of providers to determine if your preferred physician is covered in-network. If so, you can save more money choosing an open access HMO plan than paying more for a PPO plan, where you won’t even take advantage of off-network coverage. If there’s an open-source POS plan, mid-range premiums can be a good compromise if you think you might need out-of-network coverage and you don’t mind the extra paperwork.
If you end up choosing a plan with a high deductible, consider whether there is a health savings account. This option will allow you to contribute some of the pre-tax money from your paycheck to a special savings account that you can use to pay for medical expenses such as copays and medications.

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