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 healthcare provider is contracted. Members enrolled in an OAP can mix and match providers and tiers. Specific benefits are described on the benefit charts below and may also be found in the summary plan document (SPD) on the OAP administrator’s website.
A description of the coverage levels, coinsurance, copayments and deductibles applied to each OAP tier is listed below:
- Tier I offers a managed care network which provide enhanced benefits and require copayments which mirror HMO copayments.
- Tier II offers another managed care network, in addition to the managed care network offered in Tier I, and also provides enhanced benefits. Tier II requires copayments, coinsurance and is subject to an annual plan year deductible.
- Tier III covers all providers which are not in the managed care network of Tiers I or II (i.e., out of network providers). Using Tier III can offer members flexibility in selecting healthcare providers, but involve higher out-of pocket costs. Tier III has a higher plan year deductible and has a higher coinsurance amount than Tier II services. In addition, certain services, such as preventive/wellness care, are not covered when obtained under Tier III. Furthermore, plan participants who use out-of-network providers will be responsible for any amount that is over and above the charges allowed by the plan for services (i.e., allowable charges), which could result in much higher out-of-pocket costs. When using out-of-network providers, it is recommended that the participant obtain a preauthorization of benefits to ensure that medical services/stays will meet medical necessity criteria and be eligible for benefit coverage.
Members who use providers in Tiers II and III will be responsible for the plan year deductible. In accordance with the Affordable Care Act, Tier II and III deductibles will not 'cross accumulate,' which means that the amounts paid toward the deductible in one tier will not apply toward the deductible in the other tier.