What is an Open Access Network in Health Insurance?

Open Access Network

“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 your plan has an open access network, then employees can generally still see the providers they know and love without added fees. 

In this article, we’ll explore what an open access network means. We’ll also outline how open access works based on your health insurance plan, such as PPOs and HMOs.


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

Open access health insurance means employees have more freedom to see the healthcare providers they choose. Employees do not need referrals from a primary care physician. They can also be less bound by choosing providers within a network.

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 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.)


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. Here’s a quick breakdown of what open access looks like with an HMO or a PPO plan, and whether fully funded and self-funded insurance plans offer open access networks. 


HMO Plans With Open Access Networks

An HMO, or Health Maintenance Organization, is a type of fully funded insurance plan through a traditional carrier. Traditional HMOs trade lower costs for reduced healthcare provider flexibility.  They do so by requiring 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. On 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 do tend to incentivize in-network providers. Employees will typically pay more for out-of-network providers. 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. 


What Kinds of Health Insurance Include Open Access Networks?

Both fully funded insurance and self-funded insurance can offer open access networks in their plans. 

Employers choosing between fully and self-funded insurance aren’t deciding whether or not to include open access networks. Rather, they’re deciding if they want to assume control of paying for medical claims (self insurance) or pay a premium for the insurance carrier to handle (fully funded insurance). 

However, one key difference to consider between traditional Open Access PPOs and network-free Open Access plans like Sana’s are 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.  In Sana’s Open Access plans, it is never the case.

Tired of Out of Network Fees?
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Originally published Jul 29, 2020 02:39:05 PM
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Adrienne Smith July 29, 2020