Sept. 30--MONROE -- With open enrollment approaching, New Jerseyans can expect more health insurance policies like Horizon Blue Cross Blue Shield of New Jersey's Omnia plan that steer them to their insurers' top network of providers -- and away from other doctors and hospitals ranked in lower tiers, industry experts said Thursday.
The so-called tiered policy ruffled the feathers of health care providers left out of the preferred network. But the New Jersey Supreme Court sided with Horizon in a case about its Omnia plan decided Thursday. And insurers said it allows them to deliver on Obamacare's goal of slowing down the cost of health care and improving patients' health.
"If we didn't have the tiered network," said Michael Considine, Horizon's vice president, "who knows if we'd be able to survive on the (Obamacare) exchange long term?"
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Considine and other officials spoke to about 400 people at a conference sponsored by the New Jersey Association of Health Underwriters, a trade group representing insurance brokers.
They are part of an industry that is being overhauled in the wake of the Patient Protection and Affordable Care Act, better known as Obamacare. Many hospitals and doctors' offices are consolidating. Some insurers have left the state, unable to compete. And many consumers are digging deeper in their pockets to pay for their own health care.
Consumers are gearing up for 2017. Medicare's open enrollment begins Oct. 15. Obamacare's open enrollment for individuals not covered by Medicare or their employer begins Nov. 1.
What can they expect? Here are four takeways:
1. More tiered networks
Horizon caused a tidal wave last year when it introduced Omnia.
The plan offers consumers lower co-payments and deductibles if they use a Tier 1 provider. Hospitals left out of the preferred network, such as Freehold Township's CentraState Medical Center -- along with plenty of lawmakers in Trenton -- cried foul. But the New Jersey Supreme Court denied their argument that regulators should not have approved the Omnia plan.
Considine said Omnia is panning out; Horizon applied for increases of less than 5 percent, much lower than other plans.
"The proof is in the pudding," Considine said.
Hospitals left out of Horizon's top network, however, are teaming up with other insurers to create their own tiered networks. One example: Marlton-based Virtua Health System and Aetna, said Richard Miller, Virtua's president and chief executive officer.
2. Consumers are more engaged
Consumers with high-deductible plans are on the hook for thousands of dollars before their insurance kicks in, leaving them scouring their explanation of benefits bill that they previously put in the shredder without even a glance.
"Five years ago if our billing department got five calls a week, that was a lot," Miller said. "Now, we're getting hundreds of calls from consumers because they are shopping."
3. Hospitals are more transparent
Hackensack Meridian Health's hospitals in Monmouth, Ocean and Middlesex counties have put their quality measurements online. Consumers can see the hospitals' rate of readmission within 30 days of being discharged; health care-associated infections; and patient satisfaction results -- nearly in real time.
It puts the hospitals a step ahead of other quality measurement reports, which can come from data that is up to two years old, said Dr. Kenneth Sable, president of Jersey Shore University Medical Center in Neptune, which is owned by Hackensack Meridian.
"We decided to be proactive on our website," Sable said.
4. The Obamacare market will continue to shake itself out
In 2016, five insurers sold plans on the insurance exchange in New Jersey. For 2017, Health Republic of New Jersey, Oscar and UnitedHealthcare's Oxford have dropped out, leaving just two -- Horizon and AmeriHealth New Jersey.
Health Republic is in rehabilitation and could return in the future, the company's interim CEO Tom Dwyer said.
Insurers had trouble assessing the risk of consumers, many of whom hadn't previously been covered, Ken Kobylowski, the former New Jersey Banking and Insurance Commissioner who now is an AmeriHealth vice president, said after the panel.
Now, "we're able to do a more accurate job of pricing products," Kobylowski said.
Michael L. Diamond; 732-643-4038; email@example.com
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