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What is an Open Access Health Plan?

Managed health care plans in the United States extend along an "expense" continuum from the least expensive and most restrictive (HMOs) to the most expensive and least restrictive, preferred provider programs. Point-of-service (POS) health care programs combine some of the benefits of both by allowing the patient to choose the level of cost and restriction he or she prefers.
Open access point-of-service plans represent a modification of the hybrid POS health plan, which adds an additional level of charge you can choose between the program's lowest-cost option (HMO) and the more expensive preferred provider option (PPO).

  1. HMOs

    • Health Maintenance Organizations are unique in that they provide both the financing of health care costs and the delivery of care to the patient. HMOs require that subscribers have an in-network primary care physician (PCP), also called a "gatekeeper," who is responsible for coordinating (quarterbacking) the care of his or her patients by using referrals. Typically, to receive HMO benefits, you must have a referral from your PCP to see in-network specialists.

    PPOs

    • Preferred Provider Organizations (PPOs) also use a provider network. Unlike HMOs, PPOs don't require that you have a primary care physician or use only in-network resources. However, they do encourage you to use their network by offering financial benefits when you do so. Typically, PPOs do not require referrals.

    POS

    • A POS plan combines some of the benefits of both an HMO and a PPO. In a classic POS, you decide whether you will use HMO benefits or PPO benefits at the point of service; that is, when you first visit a health care provider.
      POS plans don't require that you choose a primary care physician, but they encourage you to do so. They also have a provider network, but don't require its use, though they offer significant financial incentives if you do. To use the lowest co-pay HMO portions of the plan, you must meet HMO requirements (e.g., PCP, in-network providers).

    Open Access POS

    • Open access point of service adds an additional option to the classic POS plan's referral policies.
      As in an HMO, you can decide to have your primary care physician refer you to in-network specialists and facilities. This option provides the lowest co-pay level.
      As an added benefit, open access POS plans also let you "self-refer" to in-network specialists and facilities at what the insurance companies call "discounted rates." When you "self-refer," you see a doctor, specialist or use a health care facility without having a written referral from your physician.
      Finally, as in a PPO, you can self-refer to out-of-network providers, which results in the highest out-of-pocket costs.
      Open access plans provide the same incentives as those of POS programs to encourage the use of a primary care physician and in-network services.

    Availability

    • Open access point-of-service policies are available only to employers offering, or planning to offer, group health care insurance to their employees.
      Most of the major health companies have open access group plans in their portfolios.

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