Home » Horizon BCBS OMNIA Plan Restricts Mercer County Resident Hospital Options

Horizon BCBS OMNIA Plan Restricts Mercer County Resident Hospital Options

by Mary Galioto

Horizon Blue Cross Blue Shield’s new OMNIA plan,* while created to offer cost savings, will also offer some tough choices for residents of Mercer County, especially when it comes to hospitals. OMNIA is a insurance plan alliance between HBCBS and Horizon OMNIA Health Alliance that divides hospitals in New Jersey into two separate tiers, with “Tier 1” being within network and “Tier 2” requiring substantial premiums. In Mercer County, only one hospital has been categorized as Tier 1, Robert Wood Johnson of Hamilton, and there is no hospital in “Tier 1” that offers maternity care. No hospital in Trenton is Tier 1 resulting in a major gap in health care availiabity in the state capital. And furthermore, currently, there are no out-of-state benefits, so individuals with children who might need to go out of state, to the Children’s Hospital of Philadelphia (CHOP) for example, will likely not have their health care covered at this time.

“How these hospitals were chosen to receive Tier 1 status, while 34 other New Jersey hospitals were denied this status, is a mystery,” said Assemblywoman Liz Muoio, in a written testimony submitted at the Senate hearing on Monday October 5, 2015. “Information provided by Horizon BCBS states that quality of care is central to the Alliance’s intent to ‘respond to marketplace demand for higher value care.’ However, one hospital, St. Francis Medical Center, which was the recipient of Horizon’s own 2014 High Performing Hospital Reward, was denied the ability to apply for Tier 1 status. St. Francis Medical Center is one of two hospitals located in the capital city of Trenton, both of which have been excluded from the Alliance and Tier 1 status. The second hospital, Capital Health Regional Medical Center, was never notified of Horizon BCBS’s intention to exclude them from the Alliance and Tier 1 status.”


While the OMNIA plan promises lower insurance rates for subscribers, there may be harmful consequences, namely the financial stability of hospitals in the Tier 2 category, who will likely see dwindling patient numbers as OMNIA plan members prefer the Tier 1 hospitals, according to Dennis Dooley Vice President, Communications & Government Affairs at Capital Health.*

“An estimated 250,000 HBCBS subscribers will opt for OMNIA, in the first year, providing the purchaser of insurance a discounted premium of 15% less than traditional plans however, within this, it limits choice,” Dooley explained. “For Capital Health, it could mean a loss of patients, making patients have to make a choice about they will and won’t do. We haven’t had to make core service adjustments and are doing better each day financially, but this is something that has come out of left field.”

Approval for the OMNIA plan was required by the Department of New Jersey Banking and Insurance (DOBI), which has received criticism from hospitals and legislators for having approved such plan, particularly without the knowledge or comment from major stakeholders within the State of New Jersey. “We have a situation where we feel as if the health insurance companies are starting to dictate health policy in the State of NJ instead of elected individuals in the statehouse,” said Dooley. It appears, in discussions with Assemblywoman Muoio, that DOBI was not even aware that Robert Wood Johnson of Hamilton no longer offers maternity care.

At the Hopewell Township committee meeting last night, the committee unanimously passed a resolution asserting that the effect of the tiered system would have discriminatory effects on hospitals in Mercer County, resulting in a grave risk to their solvency and sustainability and to the health needs of people in the communities that depend on them.

“I am very concerned about this issue and the implications from a standard of care standpoint and fiscal solvency perspective,” said Hopewell Township Committeeperson Kevin Kuchinski. “This is one of the most cynical anti-competitive acts by a corporation in some time. It is clearly not in the best interest of Hopewell Township residents and I suggest that the [Hopewell Township] Mayor ask the Governor to act on this to adjust this.”

The resolution calls on Governor Christie and his department commissioner to “compel immediate withdrawal of the insurer’s two-tier hospital scheme” and asks the legislature to act on this matter.

*Edited 10/15/15 to attribute the statement.

* Edited to include information from BCBSNJ:

The OMNIA Health Alliance article by MercerMe contains several items requiring correction and/or clarification. Horizon BCBSNJ appreciates MercerMe’s invitation to present the facts.

In 2016, Horizon BCBSNJ is offering all of its current standard health plans, without tiers, to consumers.

In 2016, Horizon BCBSNJ is also offering new, lower premium OMNIA health plans. Consumers who purchase an OMNIA health plan will have in-network access to all doctors and hospitals in Horizon BCBSNJ’s networks. No current network doctors or hospitals have been removed from Horizon BCBSNJ’s network. Members will have access to all current network doctors and hospitals.

The OMNIA health plans, however, place all network doctors and hospitals into one of two groups, called tiers. Members seeking care at OMNIA Tier 1 doctors and hospitals will save additional out-of-pocket costs, including lower copayments, coinsurance, and deductibles. If members use a Tier 2 doctor or hospital, they will have out-of-pocket costs that, in most cases, are similar to Horizon BCBSNJ’s standard plans.

In Mercer County, 62% of physicians are in OMNIA Tier 1 as well as one hospital, RWJ Hamilton. For maternity care, University Medical Center of Princeton is a close Tier 1 hospital.

For those individuals that would only seek care at Tier 2 doctors and hospitals, the OMNIA health plans may not be the best choice. All of Horizon BCBSNJ’s standard plans that do not tier doctors and hospitals, however, will still be available to those consumers.

Children’s Hospital of Philadelphia (CHOP) is a network hospital and would be available as a Tier 2 hospital for OMNIA health plan members.

We welcome readers of MercerMe to visit https://www.whathealthcarecostsnj.com/listening/ for information about the OMNIA Health Alliance.

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