What is an Open Access Plan in Health Insurance?

Open Access Network

What is an Open Access Network in a Health Insurance Plan?

“Can I continue seeing my doctor?” is one of the first questions employees ask about their health insurance plans. As an employer, the answer you give depends on the network in your benefits plan. If you have an open-access plan, employees can generally still see the providers they know and love.

First off, according to the Illinois Department of Central Management Services, “Open access plans combine similar benefits of an HMO with the same type of coverage benefits as a traditional health plan. Members who elect an OAP will have three tiers of providers from which to choose to obtain services. The benefit level is determined by the tier in which the health care provider is contracted. Members enrolled in an OAP can mix and match providers and tiers. Specific benefits are described on the benefit chart links below and may also be found in the summary plan document (SPD) on the OAP administrator’s website.”

In essence, open access health insurance means employees have more freedom to see the health care providers they choose. Employees do not need referrals from a primary care physician to see providers, but they may have to pay a different level of co-pay or coinsurance if they see providers outside of the tier specified by the insurance company. 

Related: The Small Business Guide to Offering Employee Benefits

 

Open access health insurance is also known as an “open access plan” or referred to as having an “open access network.” You’ll additionally see the term “open access provider.” This refers to an insurance provider offering health plans with an open access network. 

Open access plans do not mean anything goes. In fact, depending on the plan, they can vary in the degree of openness. Two common variables include: 

  • The size of the open access: Whether employees can avoid referrals for in and out-of-network providers or just for in-network ones.
  • The exceptions: Which special services, treatments, and/or procedures still need authorization from a primary care provider before an employee can proceed.

Employees with open access plans pay copays based on the employee’s plan specifics, the services provided, and whether the provider was in- or out-of-network. It’s worth noting that emergency treatment doesn’t fall into these definitions. Employees can always seek essential emergency treatment without needing a referral first.

While researching how an open access plan works, you probably read about HMOs (Health Maintenance Organization) and PPOs (Preferred Provider Organization) based on your health insurance coverage. This article will explore those concepts as well in the following sections.

Related: How to offer health insurance to my employees

Types of open access plans

As an employer, you can find open access plans across a variety of plan options. Self-insurance plans and fully-funded plans can both include open access networks. 

But, before a quick breakdown of what open access looks like, let’s compare open access HMO vs. PPO plans and whether fully-funded and self-funded insurance plans offer open access networks. Here is a review of some recent stats from 2020:

  • 47% of covered workers have PPO plans. 
  • The enrollment rate in HMOs was 13% of all covered workers.
  • There were significantly fewer covered workers enrolled in health maintenance organizations in 2020 vs. 2019 (13% compared with 19%). 

The cost of fully-funded plans is relatively high, so they are more appropriate for larger companies. In this scenario, all claim charges are under the carrier’s control, and they can raise rates every year without much explanation. Smaller businesses find this option unaffordable because they must pay a fixed rate, regardless of whether their employees use their health benefits. 

One key difference to consider between traditional Open Access PPOs and network-free Open Access plans is whether you will be charged expensive “out of network fees” for the privilege of seeing some providers. In PPOs, this is almost always the case. 

Here’s more detail to help you understand open access HMOs vs. PPOs better.

HMO plans with open access networks

An HMO is a type of fully-funded insurance plan through a traditional carrier. Conventional HMOs are relatively less pricey than PPOs but come with reduced health care provider flexibility. Participants must choose doctors that are in-network to receive any insurance coverage or reimbursement. 

Healthcare.gov defines it as “A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.”

In simpler terms, these plans require employees to choose an in-network primary care physician who must provide a referral for employees to see an in-network specialist. An Open Access HMO typically allows employees to see in-network specialists without a referral but will not cover out-of-network providers other than emergency care.

The gist: Open Access HMOs are less expensive but more limiting than a PPO.

PPO plans all have open access networks

A PPO, or Preferred Provider Organization, is a type of fully-funded insurance plan through a traditional carrier. Participants may select doctors and specialists out of the carrier’s network with the tradeoff of a pricier insurance plan. 

Healthcare.gov explains that PPO is “A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.”

In other words, with a PPO plan, employees don’t need a referral when choosing providers — whether in- or out-of-network. Open Access PPO plans are more flexible than HMO plans but tend to incentivize in-network providers. Employees may see out-of-network providers but will typically pay more to do so. PPOs are often more expensive than an HMO plan, and so employees will see higher deductibles and premiums. 

The gist: PPOs are, by definition, open access. They are more flexible in which providers you can see, but you pay more than you would with an HMO. 

Related: When employers should switch to self-funded health plans

What kinds of health insurance include open access networks?

As mentioned above, both fully-funded insurance and self-funded insurance can offer open access networks in their plans. However, employers choosing between fully- and self-funded insurance plans aren’t deciding whether or not to include open access networks. Instead, they’re deciding if they want to assume control of paying for medical claims (self-funded insurance) or pay a premium for the insurance carrier to handle (fully-funded insurance).

Self-funded plans

Compared to a fully-funded health care plan, self-funded plans are a more affordable small business health insurance option. A self-funded health plan may be called “self-insurance,” so you can use the terms interchangeably. Participants may choose their providers without seeking referrals.

The plans’ affordable nature and flexibility are the primary reasons for self-funding’s increasing popularity as a small business health insurance option. With self-funding, the employer is responsible for paying enrollees’ medical claims. An employer who sponsors a self-funded plan typically contracts with a third-party administrator or insurer to offer administrative services. 

Even though self-funded plans are more affordable and flexible, they do come with risks of catastrophic claims that can wipe out your budget. You can purchase stop-loss insurance separately to ensure you do not have to pay excessive claim amounts, but you have to factor in the cost of this type of insurance in your budget. 

Level-funded plans

A level-funded plan (a.k.a. level-funding plan or partially self-funded plan) is a type of self-funded coverage that includes monthly cash flow stabilization. As such, you will only be paying for the health insurance you use, just like with any self-insurance plan, which makes it a small business-friendly health insurance option. However, with level funding, costs are capped. Stop-loss insurance is built into your premiums, and you get reimbursed at the end of the year for any overpayments. 

Level-funded plans also enable participants to select providers of their choosing without a referral. 

Sana’s PPO Plus plans take it one step further. Instead of different levels of coverage for providers in an ‘open-access’ plan, Sana’s network is completely all-access. You’re never restricted by a network, forced to pay out-of-network fees, or required to get a referral.  You can see any doctor you want, anytime, and enjoy modern benefits for you and your employees. Learn more now.

Originally published Oct 25, 2021 09:39:05 AM
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Adrienne Smith October 25, 2021