What does 'open access' mean on a small group health insurance policy?

Answer 1

While insurance companies may define the term "open access" specifically for their own products, the term generally means that the provider network(s) available to the plan in question can be used freely without a referral from a Primary Care Physician (PCP). So for example, an "Open Access HMO" usually means you do not need a referral from your PCP in order to see a specialist as long as that specialist is within the HMO network in question.

Whether a plan is open access or not does not have any baring on whether you can see health care providers outside of the specified provider network(s) for non-emergency services. It is possible to have an "Open Access HMO" (typically with no benefits outside of the network) or an "Open Access POS" (Point-of-Service plan that includes out-of-network benefits). It is generally considered redundant to say a PPO plan is open access, since PPO plans generally do not require referrals from specialists by nature of their design.

It should be noted that other provisions of the insurance contract related to the access to care itself (rather than the access to certain types of providers) are usually unaffected by an open access feature. For example, tests of medical necessity, pre-authorization requirements for specific types of services, "step therapy" and other managed care strategies are usually still applicable even though referrals for specialists are not required.

In all cases it is recommended that you contact your health insurer directly to clarify these and other plan attributes before receiving services so that you can avoid any unpleasant surprises.

SOURCE: http://www.bcbs.com/coverage/glossary/#o