Horizon Blue Cross Blue Shield of New Jersey’s Omnia health insurance plan needs to be more tightly regulated so that hospitals and doctors have a better chance to be included in its preferred network, a key Republican lawmaker said Thursday.
Jon Bramnick, the Assembly Republican leader, also said Horizon’s Omnia plan unfairly disparages health care providers through the terminology it uses: Tier 1 for hospitals and doctors in its preferred network, Tier 2 for the others.
“I don’t believe insurance companies should pick and choose who gets the patients and who doesn’t get the patients,” Bramnick said.
In a press conference here, Bramnick joined a chorus of lawmakers – mostly Democrats – who have tried to stop Horizon from rolling out its plan. So far, they haven’t been successful.
Newark-based Horizon, the state’s biggest health insurer with 3.8 million members, introduced the Omnia plan last year to go into effect in 2016. While open enrollment for this year has ended, consumers who have a life-changing event can still purchase a policy.
Omnia works like this: Consumers who use so-called Tier 1 providers will have lower out-of-pocket costs. Consumers can still see Tier 2 providers but will pay more. Horizon touted the plan as an example of what was intended by the Patient Protection and Affordable Care Act, or Obamacare: better care at lower prices.
Tier 1 includes 34 hospitals statewide, including Monmouth and Ocean County hospitals owned by Barnabas Health and Meridian Health. Tier 2 has about 27 hospitals statewide, including CentraState Healthcare System in Freehold Township, the only Jersey Shore hospital not in Tier 1.
Horizon isn’t alone. AmeriHealth New Jersey and Aetna both have partnered with health care providers at the Shore to create tiered insurance plans. But Horizon has 56 percent of the individual health care market, according to the New Jersey Department of Banking and Insurance, making it far and away the biggest carrier.
Hospitals left out of the top tier have cried foul and filed lawsuits to stop the plan. Among their arguments: the New Jersey Department of Banking and Insurance didn’t assess the risks the plan would have on the state’s health care system.
Horizon officials said Omnia is part of a bigger picture. Health insurance companies are beginning to pay providers not on how many services they provide but on the outcome, weeding out unnecessary costs.
It says the strategy saves money. In one program with 51 specialty medical practices, Horizon had fewer customers who had to be readmitted to the hospital after receiving knee arthroscopy, hip replacement and knee replacement. And it saw fewer unnecessary C-sections, it said earlier this week.
Bramnick on Thursday stood alongside hospitals, doctors and other lawmakers, who said Horizon has been heavy-handed. And not all of them objected to the idea of tiered networks; only that they weren’t given the chance to see if they could meet Horizon’s standards.