As of February, 234,500 people were enrolled in an OMNIA plan
TRENTON -- The debut of health insurance plans seldom makes big news. But when Horizon Blue Cross Blue Shield of New Jersey, the state's dominant insurance carrier, announced it would offer consumers significant savings through its OMNIA tiered-network products, the entire healthcare industry in New Jersey took notice. Some took Horizon to court.
1. How did it begin?
In September 2015, Horizon introduced a line of insurance products that promised to save customers 15 percent on premiums compared to other Horizon plans, plus additional savings on out-of-pocket expenses. The catch: policy holders, if they want to save the most money, have to pick from 36 "tier 1" hospitals that have agreed to accept smaller reimbursements from Horizon for more patient volume.
Images of the Horizon Blue Cross Blue Shield headquarters in Newark. (Matt Smith | For NJ Advance Media)As of February, 234,500 people were enrolled in an OMNIA plan after the first open enrollment period. Most of the enrollees -- 189,200 -- bought the policies themselves, including 154,250 through the health exchange created by the Affordable Care Act. About another 45,240 people enrolled through their job.
3. Who doesn't like it?
Many of the 32 hospitals Horizon forced into tier 2 status have complained because patients who choose them won't get the same savings. The tier 2's argue this hurts consumers because Horizon is limiting their choices. Tier 2 hospitals are smaller, mostly independent, with some run by the Catholic church; many are located in cities. Some hospitals have sued Horizon to force their way into the top tier.
Saint Peter's University Hospital in New Brunswick is one of the hospitals that has filed suit against Horizon over its tier 2 status in the OMNIA plans. (Ed Murray | NJ Advance Media)4. The case against OMNIA, part 1:
Tier 2 Hospitals say because they are part of Horizon's network, Horizon is contractually obligated to give them an opportunity to join tier 1.
5. Horizon's reply:
Horizon argues tier 2 hospitals are still "in network" so their contracts remain intact.
Robert Marino, CEO of Horizon Blue Cross Blue Shield of NJ. (Courtesy of Horizon)6. The case against OMNIA, part 2:
Hospitals argue the tier 2 label hurts their reputations, sets them up for major financial losses, and could force mergers or closures.
7. Horizon's reply:
The insurance company's obligation is to offer reasonably priced insurance coverage to the public.
8. Who is Pro-OMNIA?
The state's largest state worker union, Communications Workers of America, whose members may select OMNIA; some private-sector labor groups, Senate President Sweeney and some other legislators; some business groups.
Senate President Stephen Sweeney (D-Gloucester), seen in this file photo, has been an outspoken defender of Horizon's OMNIA plans, citing their cost-savings for consumers. (Reena Rose Sibayan | Jersey Journal) 9. Who is against OMNIA?
Catholic bishops and several state lawmakers with tier 2 hospitals in their districts.
10. Who is winning?
Horizon so far. The state Appellate Court has sided with state's decision to approve OMNIA. Judges have declined to halt enrollment, a step sought by tier 2 hospitals. Sweeney has promised to block legislation that interferes with OMNIA.
11. What happens next?
An appellate court is expected to decide soon whether Horizon has to turn over confidential information the company used to select hospitals for the top tier.
Richard J. Hughes Justice Complex in Trenton, where the appellate judges convene. (Michael Mancuso | For NJ.com )
Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio. Find NJ.com Politics on Facebook.