Horizon Blue Cross Must Turn Over Data on Narrow Network Plans

A New Jersey judge ruled that Horizon Blue Cross Blue Shield must make a consulting report that led to the development of it’s narrow network OMNIA plans available to the public.

Horizon is NJ largest payer, covering more than 3.8 million of the state’s residents. In 2015, the insurer created its line of narrow-network OMNIA plans with the help of a consult’s report. These plans offer premiums at an approximate 15% discount to a standard plan, but require patients to use a tiered-provider system in order to realize those savings.

OMNIA plan providers are split into “tier 1” and “tier 2” levels. Plan members can save by visiting “tier 1” providers and hospitals, but face higher rates at “tier 2” providers and hospitals. Health systems in “tier 1” have agreed to lower reimbursement rates in exchange for higher patient volume; however, health systems in “tier 2” filed a suit claiming that they lose patient volume and money as a result of “tier 2” status.

State Superior Court Judge Robert P Contillo determined that releasing the consulting report that led to the development of the Horizon’s OMNIA plans is in the public’s best interest. He argued that value-based care at the detrimenant of “tier 2” hospitals is not ultimately good for NJ health insurance members.

“The public interest is not confined to what Horizon says about how it structured OMNIA and created Tier 1 and 2, or awarded participation, but also how it hopes to achieve these goals, by incentivizing value-based, result-based health care at the alleged expense of those network partners designated as Tier 2,” he said.

The “tier 2” health systems are also suing for the right to qualify for “tier 1” status.

—David Costill

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