Managed Care Plans (MCP)
Open Access Plan (OAP)
Open Access Plans (OAP) combine the benefits of Health Maintenance Organizations (HMO) and traditional health coverage. The plans offer two managed care networks, Tier I and Tier II. Enhanced benefits are available by utilizing providers in Tier I and Tier II. In addition, Tier III benefits (out-of-network) are also available giving plan participants flexibility in selecting healthcare providers, but requires higher out-of-pocket costs. The provider and tier selected for each service determines the level of benefits available.
OAPs allow plan participants to mix and match services between Tiers I, Tier II and Tier III. For example, a plan participant can utilize a Tier II physician and receive care at a Tier I hospital. The OAP plan administrator’s website provides a directory that contains listings of the Tier I and Tier II networks. With the OAP, you have the flexibility to choose any provider, in- or out-of-network, and still receive some level of benefits. The benefit level for services rendered will be the highest if selecting Tier I providers.
- Tier I is often a 100% benefit after a copayment.
- Tier II is generally a 90% benefit with a 10% coinsurance after the annual plan year deductible is met.
- Tier III (out-of-network) is generally paid at 60% of Maximum Allowable Charges (MAC) based on Medicare rates in a geographical location, after the annual plan year deductible is met.
Tier II and Tier III both have an annual plan year deductible. These deductibles cross accumulate, which means that the deductible paid for services in one tier will be applied toward the deductible in the other tier.
Prescription drug deductibles and copayments you pay apply to your out-of-pocket maximum; therefore, when you reach your out-of-pocket maximum, eligible medical, behavioral health and prescription drug charges will be covered at 100 percent for the remainder of the plan year.
Points to consider in making this choice:
- Preventive and well-care services, such as routine physicals and pediatric care, are provided at no additional cost. Covered under Tier I and Tier II only.
- Co-payments apply to doctor's office visits, prescriptions, hospital admissions, emergency room visits and some other services.
- Deductibles apply to the Tier II and Tier III (Out-of-Network) benefits.
FY 2017 Benefit Choice Options booklet (As of July 1, 2016)
CMS OAP Overview