HORIZON BLUE CROSS WARNING AND QUESTION

Horizon BC/BS is pushing new "Omnia" plans, which their marketing materials claim a wider network with lower premiums and lower deductibles. I figure: there's got to be a catch. Called, and after a lot of time on hold and lots of fraught discussion, found out indeed there is a catch. In my existing Advantage plan, all doctors and hospitals in their wide network are the same. In Omnia, there are Tier 1 and Tier 2 doctors and hospitals. You can in theory go to Tier 2 but there's all sorts of payments involved -- they are highly incenting you to go to their smaller Tier 1 network. (BTW: "Tier 1" sound fancy, right? No. Don't think "Tier 1 must be the most sought after doctors," it's the opposite -- they want to send you to their Tier 1 less expensive doctors, Tier 2 is are more sought after ones they're trying to keep listed in their network but make it costly for you to go see).

My concern has always been if the sh*t hits the fan and major medical care, that I can go to the best doctors. This was the case with Advantage (thank God I never needed it) but I'm not sure if it is with Omnia. I can't figure out if after I pay the $6850 max out of pocket, if my access to doctors, hospitals and care would be the same or different with these two plans.

Any ideas about this or general Omnia vs. Advantage? BTW, my Advantage Bronze goes from $675 to $775 if I want to keep it -- which sucks (really, 15% increase in one year?? After a big hike last year??).

THANK YOU for any insights you can offer.

There has been a lot of news coverage of this. It is controversial. But I take issue with the characterization of the Tier 1 as less sort after or somehow inferior. There are many fine Tier 1 hospitals.

The rationale for the plan is that by creating a smaller network and funneling a lot of business to the providers in that smaller network those providers will gain volume which will allow them to be able to prosper even though they agree to a lower reimbursement rate. They are actually being sued by providers who wanted to join and the reimbursement rate but were denied because Horizon was limiting the network to assure volume to the in network providers.

It really gets to the heart of the issues with healthcare and what the best way forward is. 

I checked before we went to Omnia..almost all of our current doctors are Tier 1 anyway.And the cost for Tier 2 wasnt that much more, IIRC.

But bothers me most is that their is NO coverage outside of New Jersey. With trips to NYC almost weekend, that is a much more significant problem.

We've been wrestling with this.  Health Republic, which we have for this year, does have a network that includes NYC doctors (through "Multiplan" network). Not sure if any of the others do.  I'm still considering a change because of big premium  increase.

If this has not already been said on the various ACA threads, note that individual family members can sign up for different plans.  

librarylady said:

I checked before we went to Omnia..almost all of our current doctors are Tier 1 anyway.And the cost for Tier 2 wasnt that much more, IIRC.




But bothers me most is that their is NO coverage outside of New Jersey. With trips to NYC almost weekend, that is a much more significant problem.

@LibraryLady, I don't understand what you mean by the cost for Tier 2.  Do you mean in terms of co-pays?  

As for coverage outside NJ, if something happens in NYC or anywhere else, emergency room visits are covered. But yes, longer term health concerns need to be treated in NJ, from what I understand, which cuts out a lot of fabulous NYC hospitals and physicians. 

yes you can go to a tier two doc but the co-pay is more  the docs we currently use are all tier one

My big concern is that NYC docs and hospitals are closer  for us  and better than Jersey docs in Mercer  County     Just doesn't    make sense to me  

@librarylady  Health Republic has doctors in NY as well as NJ. I don't know the quality of those docs, but they do.

my agent said that some of the Omnia doctors are in New York, but I don't believe him and I haven't checked 

wow no one ever said THAT before  

Thank you!  This is very helpful.

I had an Amerihealth plan with national coverage (multi plan) and am going to switch to a regional plan this year.  They are required to cover medically necessary procedures etc if you are out of state, and it is so much cheaper that I can pay full rate at my nyc chiropractor and still save a ton of money.  I'm looking at omnia plans, and agree that the tier thing is shady, but all of our doctors are tier one.  Overlook hospital is tier one as well...

I'm on the same Amerihealth plan - I was worried about being able to see doctors in NYC so went with it last year.  I've also found it not worth the price.  Especially since a lot of people I wanted to see didn't end up taking multi plan anyway.  And I really hate their customer service.  I'm switching to the Blue Cross OMNIA plan - way more reasonable and from looking at the directory, we are going to be ok with the tier issue with docs we are already seeing in NJ