Other states may hold answer to New Jersey's Omnia dilemma

As the controversy continues over Horizon Blue Cross Blue Shield of New Jersey's Omnia health plans, some say it's worth looking at other states to decide how to regulate tiered networks, according to NJ Spotlight.

Horizon's debut of Omnia has been met with strong opposition from some hospitals and lawmakers in New Jersey, who claim that the process of choosing Tier 1 and Tier 2 providers was neither transparent nor fair.

The insurer has defended Omnia, with CEO Bob Marina previously telling FierceHealthPayer that Horizon created the new health plans in response to concerns about rising healthcare costs in the state, and chose Tier 1 systems based on their commitment to value-based care and clinical quality.  

Still, the debate has led some in New Jersey to call for legislation that would require more transparency from health plans in creating tiered networks. And there is precedent for that elsewhere in the country, Ray Castro, a healthcare expert with the left-leaning organization New Jersey Policy Perspective, tells NJ Spotlight.

Other states are approaching regulating tiered networks through the model regulations drafted by the National Association of Insurance Commissioners, according to Castro. New Jersey especially may want to consider the part of the model law that prohibits insurers from using criteria to create networks that discriminate against high-risk patients or the providers who treat them, he adds. 

Other insurers have created more transparent tiered-network plans, experts tell the publication. For instance, Blue Cross Blue Shield North Carolina lists on its website the quality measures and tiering methodology it uses to create its plan called Blue Select and offers providers an appeal process to contest their tier designation.

The issue of how to regulate health plan network adequacy continues to gain attention as narrow-network plans become more prevalent on the Affordable Care Act exchanges. Recently, the federal government said it will try to increase consumer awareness by rating health plans' network size on the Healthcare.gov platform.

To learn more:
- read the NJ Spotlight article

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