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NJ Supreme Court Won't Hear OMNIA Case

Mary Caffrey
In the year since New Jersey regulators approved OMNIA, the state's health insurance market has experienced the same upheaval seen elsewhere: the number of options on the exchanges has shrunk from 5 to 2.
New Jersey regulators’ 2015 approval of Horizon Blue Cross Blue Shield’s OMNIA health network withstood its last test yesterday, when the state Supreme Court declined to hear an appeal from a group of hospitals.

Critics of OMNIA seemed to acknowledge their limited options, as a statement from the hospitals’ attorney referenced not remaining legal paths, but the legislature, which was the scene of a marathon hearing a year ago when the tiered health plan first caused a storm of controversy.

OMNIA is 2 things at once: a tiered network plan to address affordability in one of the country’s highest-cost states, and an alliance of physicians and hospitals that Horizon handpicked for the state’s largest population health venture to date. Consumers who picked OMNIA saved about 15% on premiums and could avoid significant out-of-pocket costs by using a select group of providers. The plan generated pushback when many of the state’s urban, safety net hospitals were left out of the alliance and OMNIA’s preferred tier.

“The Supreme Court’s decision is another win for OMNIA and for consumers seeking relief from skyrocketing medical bills. Healthcare costs are a major problem for New Jersey employers and patients, and while some are content to be part of the problem, Horizon is committed to being part of the solution,” said Robert A. Marino, Horizon’s chief executive officer.

Hospitals opposed to OMNIA hired a former Commissioner of the New Jersey Department of Banking and Insurance (DOBI) to argue that regulators failed to act in the public interest in approving their tiered health plan. But in June, an appellate court agreed with arguments from current regulators that state law bars them from looking at broader market impacts when deciding whether to approve a tiered network.

In last year’s testimony and in a subsequent order, DOBI argued that its time and distance standards were already among the strictest in the country, and to venture into issues beyond what the law requires would be “arbitrary and capricious.” The order acknowledges that current rules did not envision the dynamics that are remaking the healthcare landscape under the Affordable Care Act (ACA).

“We remain hopeful that the state legislature will swiftly act on pending legislation to ensure that greater fairness and transparency is required in the design of health plans in order to properly protect consumers, lower healthcare costs, and avoid potential negative consequences in the healthcare marketplace,” said hospital attorney Steven Goldman.

In the year since OMNIA was approved, New Jersey’s health insurance market has been shaped by the same events causing upheaval across the country: departures by UnitedHealthcare and another plan, as well as the recent failure of its co-op, Health Republic Insurance of New Jersey, have left the state with only 2 options in the ACA exchanges: Horizon and Amerihealth NJ. Aetna and UnitedHealthcare still participate in the state’s small group and individual markets, and Aetna offers a competing tiered network plan for public employees.

When it was unveiled last year, Horizon predicted OMNIA would attract 250,000 consumers the first year. The insurer announced a total of 234,000 in February; it did not have an update available yesterday.

If New Jersey’s state government website is any sign, tiered networks must be a boon for employers. Open enrollment for public workers in New Jersey’s State Health Benefits Program begins Monday, and the state website touts financial incentives for those who agree to enroll in either OMNIA or Aetna’s tiered plan for 2 years: $1000 for single coverage, $1250 for parent/child, and $2000 for family coverage, payable with a gift card.

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