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What is closed access?
In the insurance industry, closed access refers to situations in which those insured will be reimbursed for the initial visit to only one primary care physician. This physician then becomes the “gatekeeper,” and is the only one allowed to refer patients to other health care providers within the insurance plan for more specialized care.
Some forms of health maintenance organizations, or HMOs, have been around since 1910, when the Western Clinic in Tacoma, Washington, offered lumber mill owners and their employees certain medical services from its providers for a premium of 50 cents per member per month.
But, they became more prevalent in the 1970s when the Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional health care benefits.
To be sure, HMO group plans are common health care options offered to employees’ for insurance benefits. Most HMO plans operate under the closed access model that is also referred to as “closed panel” or “gatekeeper” models.
Under this model, selecting a primary care physician from the HMOs network of doctors is the first step in receiving medical care in most cases. Occasionally, some plans allow patients to seek the medical expertise of a specialist like an OB/GYN or dermatologist, without first seeking the opinion of a primary care physician.
Generally, once a patient establishes a relationship with a primary care physician, he or she can then be referred to other medical professionals for specialized care.
To be a part of the health insurance company’s network, medical professionals agree to provide treatment services at a certain cost to those who are eligible.
Often, doctors who participate in the closed access plan are a part of practices with several other health professionals, who agree to perform certain services at a fixed premium.
Once the insured selects a doctor from the HMO plan, the insured’s beneficiaries also must select a doctor from the network. Because the plan holder is already under the care of a certain practice, the insured’s beneficiaries are also accepted by the physician.
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Closed access example
Harvey’s employer offers an HMO option in its health care plan, but before Harvey can obtain health care, he must first choose a primary physician from the list of doctors that offer services in the HMO’s network.
After going to that doctor, he is able to get a referral to go to a specialist for back pain.
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