NJ Health Insurance

Review of Horizon BCBSNJ Omnia – Everything you need to know about Omnia Plans

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Horizon OMNIA Plans

Horizon Blue Cross released their new set of plans as of January 1, 2016 and they have created a ton of press, both good and bad. I won’t go over the criticisms of the plan, but I will cover what patients and business owners need to know before enrolling in one of the Horizon BCBS Omnia plans.

*The short summary is that these are great plans that everyone should look at to save money in premiums and out of pocket costs at their providers.


Horizon BCBS Omnia Explained

Blue Cross released these plans with their major goal of providing some lower priced plans for consumers and encouraging quality of care with financial incentives to your doctors. They hand selected certain providers that have proven success of providing good low cost care and other metrics they decided were important. Some of the goals that were established were; lowering re-admissions to the hospital, infections and other costly issues that can arise through normal course of care. So if you needed surgery and have to be readmitted to the hospital in a month because of complications, the provider would not get any incentives for that. If your doctor does the perfect job every time with no infections, no re-admissions etc.. that provider would receive a financial bonus. Its good for you and the doctors. (As an aside, you would think that would be the goal anyway but…. that’s a story for another day)

Omnia Network

The Horizion Omnia network continues to be confusing to people and I can certainly understand why. All of the literature that Horizon has put out is basically just patting themselves on the back for their great new product and how great the hospitals are and other things that don’t really help with understanding the plan.

The hospitals in the Omnia plans are IDENTICAL to the normal Horizon Managed care network. So if you had HMO, Advantage, POS or EPO, your hospitals have not changed… What has changed is what Tier structure those hospitals fall into. The Omnia plans use a Tier structure so you pay less at Tier 1 providers than you would at Tier 2.. If your provider is Tier 2, you can still visit those doctors but it will be higher cost.

Horizon BCBS List of Tier 1 and Tier 2 Hospitals

Depending on if you are in a small group plan or large group, the Tiers will be slightly different. In South Jersey, there is a large difference. Atlanticare is Tier 1 for Midsize market and Tier 2 for small group. Shore Memorial hospital is Tier 1 for small group and Tier 2 for midsize.

Find your doctor:

Go to and use their provider finder.

bcbs omnia

When you are doing your search, make sure you select the plan that you have in the drop down list.

Midsize and Large Group:

Select: Omnia

Small Group and Individual:

Select Omnia Silver, Omnia Bronze etc…


Omnia Deductible and Max Out of Pocket

With the exception of the Bronze and H.S.A, the Omnia plans do not have deductibles for Tier 1 providers. You will also notice that there are different maximum out of pockets listed for each Tier.

If you see a Tier 1 provider, that service will accumulate towards your Tier 1 Max and deductible if it applies. Those costs will also cross accumulate to your Tier 2 max.

If you see a a Tier 2 provider, those costs ONLY count towards Tier 2.. They do not cross accumulate back to Tier 1.

Omnia Frequently Asked Questions – FAQ

  1. Do I need to select a primary care doctor?
    1. Nope, although you will pay the lower copay.
  2. Do I need referrals?
    1. No, they are all no referral plans
  3. Can I go out of network?
    1. No, this is in network only unless it is an emergency
  4. How are prescriptions covered?
    1. Prescriptions are all Tier 1
  5. How is urgent care covered?
    1. From what I have seen, all urgent care centers are Tier 1 for 2016. Even if the hospital is Tier 2..
  6. Do I get BlueCard nationwide access?
    1. The midsize plans do have BlueCard attached, but the small group and individual plans do not.
  7. My doctor says they don’t take Omnia, now what?
    1. Double check this.. Many people think that if the provider is not Tier 1, they aren’t part of the network. This is not true.  Always double check with the website and ask for clarification. Get help from your broker with this.
  8. How is it fair that Horizon can pick and choose the Tier 1 hospitals?
    1. This is one of the criticisms on the plans and we will see what happens. There are many people fighting this.
  9. What if Horizon is told they can’t sell these plans anymore because it is not fair in how they selected their providers?
    1. If this does happen, Horizon will likely change the plans at renewal and you will need to select a new plan. Not much different than what they have been doing.
  10. I’m interested in learning more, what do I need to do?
    1. You can reach out to me anytime and I will review the plans and prices with you.
  11. What is the best Omnia Plan?
    1. I’m going to ignore the benefits and base my decision on the best value. Of all the plans I’ve reviewed, I like the H.S.A option and is what I personally own. The out of pocket limit is much lower than the other plans for their Tier 1 providers at $3500 annually.

This Week's Top Health Insurance News

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helath insurance newsThis will be my first of an ongoing weekly round up of insurance news from around the web. Enjoy!


Top Health Insurance News for the Week

  1. Cheap Health Insurance Beware from Consumer Reports – Good warning showing that you get what you pay for!
  2. State by State Guide To Guaranteed Health Insurance– Thanks to Zanebenefits for the link. Guide for all states so consumers can find guaranteed issue health insurance.
  3. How to Spot Medical Billing Errors in 5 Minutes– Another great article from Mintlife Blog on sorting out your medical bills.
  4. What your doctor needs to hear so you get the best possible care. – This one is not necessarily about insurance but it is about taking care of your health. A doctor sheds some light on making the most of your appointments.
  5. What is COBRA?
  6. What are some of the effects of the PPACA?
  7. IRS Helps Self Employed Seniors Paying their Medicare Part B Premiums – self employed seniors could not deduct Part B premiums…until now!
  8. Here is what the new  health insurance labels will look like. – Thanks to the Consumerist for posting this one. The new government guides look a lot better than what is out now.
  9. White House Tweaks Rule Requring Employers to Cover Birth Control
  10. Buying Individual Dental Insurance Online – Ok this isn’t from the last week but a good article nonetheless. Thanks to Wisebread for the article.


Horizon Blue Cross Blue Shield: How to read your health insurance claims EOB.

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Horizon Blue Cross Blue ShieldAs I mentioned in a previous post about health insurance claims, one of the first steps is to review the EOB. Horizon Blue Cross Blue Shield has put together a nice one page sheet to help members understand how their claims were processed.


EOB and Insurance Claims Notes From Horizon Blue Cross Blue Shield


Part of making the most of your health care coverage is understanding how your plan pays your claims and what your role is in that process. Horizon Blue Cross Blue Shield of New Jersey provides you with an important resource called an Explanation of Benefits (EOB) to do this.


The EOB is a document you will receive after you see a physician or other health care professional, at the time your claim is processed. On the EOB you will find claims and patient payment information for you and your covered family members on a single statement. The sample EOB below provides an overview of the information and what it means to you.

Horizon Blue Cross Blue Shield – How to Read EOB – PDF



If you are current client and need assistance, contact Mike Sheeran  or your dedicated account consultant at Glenn Insurance. You may also contact Horizon Blue Cross Blue Shield directly below.


Contact Horizon Blue Cross Blue Shield

If you have questions about
how to read your EOB, call
Member Services at
1-800-355-BLUE (2583).

Health Insurance For Real Estate Professionals

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The Press of Atlantic City recently covered a story on the problems real estate professionals can have securing health insurance for themselves and their families. The story titled, Health Insurance a Problem for Most Real Estate Agents,  mentions that approximately 1 in 4 real estate agents are without coverage. This is an alarming number and I’d like to share how real estate professionals can secure coverage whether through the real estate office or on their own with an individual policy.


Health Insurance Options for New Jersey Realtors


1)Group Health Insurance Through Real Estate Office

Many realtors don’t realize they may be eligible for group coverage through the real estate office they work through. NJ based businesses have the option to either include or exclude all of their independent contractors.


Eligibility Guidelines

In order to offer the coverage, a few conditions have to be met:

  • At least 75% of eligible employees must be covered by the group plan or have credible coverage elsewhere. Credible coverage means Medicare, other group coverage, group coverage through a spouse, NJ Family Care or Medicaid.
  • Your company must have at least 2 full time employees – although contractors can be made eligible, they do not count toward the employee count. As an example, an office with two full time office admins and 20 agents would work, but an office with one owner and 20 agents would not.
  • The real estate office must contribute at least 10% of the total premium.
  • Independent Contractors must fit the definition provided by the State of NJ to be eligible. This is the definition provided by the State:

The independent contractor must meet the SEH Program Act’s definition of an eligible employee (even though independent contractors will not be counted as eligible employees). In general, a person who is an independent contractor can be an “eligible employee” for purposes of the SEH Program Act if he/she: (1) is performing a service for the employer pursuant to a written contract for monetary or other legal consideration; (2) works 25 or more hours per week for the employer; (3) works on other than a temporary or substitute basis; and, (4) the independent contractor relationship has been established to serve a substantial business need of the employer and is not intended primarily to obtain insurance coverage.

See the State DOBI Website for more information


Advantages of Purchasing Your Insurance As a Group

  • Lower premiums – Your group will be rated by the insurance carrier based on your age/sex/location demographics so the actual premiums can vary depending on your group. Most groups will find that the group prices are much less expensive than a comparable individual policy.
  • Plan Options – You will be able to purchase a much wider range of policies through the group compared to the individual market. Also, individual policies only offer a 50% prescription card but there is no such limitation on a group policy.
  • Health Savings Accounts/High Deductible Health Plan – there are no HSA options in the individual market in NJ. A high deductible health plan/HSA option is usually the least expensive plan available. Some premiums are as low as $200/month for a single person and around $500 for a family. Also a HSA allows you to pay for certain eligible medical expenses on a pre-tax basis.
  • Nationwide Coverage- If you or your family travel a lot, there are options to purchase a plan with national in-network access. Individual plans do not offer this option.


Disadvantages of Purchasing Insurance As a Group

  • Many insurance carriers recently changed how many plan options a company may offer. This means that your group may have to come to a consensus on two to three different plans. If your office has twenty or thirty agents, this can be tricky. I always recommend a HSA option, a low option(high copays,  high deductible), and a premium option with lower co-pays and better prescription card.
  • Participation Issues – meeting the 75% participation can be difficult at times depending on the group. If you have a few people who do not want coverage, they can make your company ineligible. Unfortunately, there is no way around this.
  • Annual Certification – Each year, small businesses must provide proof to the insurance carrier that they still meet participation. This means, you have have to collect 1099’s from each contractor and valid waivers from everyone to prove eligibility.


2)Individual Health Insurance

If your real estate office can’t or won’t offer group coverage, you still have the option of purchasing your own individual health plan.  To be eligible for individual coverage, you must meet the following conditions:

  • Be a NJ Resident
  • Not be eligible for Medicare
  • Not eligible for coverage under a group health plan, governmental plan or church plan


I recently posted resource guides for people looking to secure individual health coverage. Please read through the links below to get more information on the different plans available and all of your options. In addition to regular individual coverage, you may also be eligible for NJ Family Care, NJ Protect or Medicaid.

1)Top Eight Resources for Uninsured New Jersey Residents to Get Health Insurance

2)Resource Guide For New Jersey Individual Health Insurance

3)NJ Individual Health Coverage Program Buyer’s Guide




Advantages of an Individual Health Plan

  • You may choose any plan that fits your needs and budget.
  • Coverage can be started and terminated any time.

Disadvantages of an Individual Health Plan

  • Limited Options – there are not as many plan options in the individual market compared to the group market.
  • Pricing – You will most likely pay higher premiums with these compared to a group plan
  • Prescription Drugs- The best prescription drug coverage you can get is the 50% coinsurance option.



If you are a New Jersey realtor and have any questions on obtaining health insurance coverage for your office or for your family, please contact me here for more information.


Flexible Spending Accounts-FSA : Frequently Asked Questions

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In an earlier post about getting the most bang for your buck with your health care expenses, I mentioned FSA’s as one of your first tools to save some tax dollars.

If you have already started the process of setting up an FSA or are just not sure about them  yet, here are some of frequently asked questions that may help clear anything up.

Flexible Spending Account Frequently Asked Questions

I am not a tax professional, or legal counsel, so please consult with your advisor before acting on any tax advice.


1)What is a flexible spending account(FSA)?

A flexible spending account is a voluntary plan that provides the opportunity to convert part of your salary into tax-free benefits. 

The spending account will allow you to set aside pre-tax dollars from your paychecks to cover eligible health care expenses for medical, dental, vision and more.


2)If I put part of my salary into a FSA, won’t I make less money?

Your spendable income may actually increase by using an FSA. Lets look at an example.

Without FSA:

Taxable income of $50,000

FSA Contribution: $0

Subtract Federal and Social Security Taxes: $13,697

Health expenses: $2,000

Spendable income: $34,303


With FSA


Taxable income of $50,000

FSA Contribution: $2,000

Taxable income is now: $48,000

Subtract Federal and Social Security Taxes: $12,983

Spendable income: $35,017

SAVINGS of $714

****This is just an example of typical tax savings. Actual results may differ depending on your exact situation.



3)Why should I bother with the FSA when I can just take a deduction on my medical expenses on my tax return?

Medical expenses have to exceed 7.5% of your Adjusted Gross Income to be deducted on your tax form. FSA’s do not have to exceed that level. If your AGI is $50,000, than your expenses have to exceed $3750.

***As mentioned above, speak to your accountant to see how this will impact your overall situation.


4)Does a flexible spending account replace my existing insurance plan?

No, the FSA is meant to supplement those plans and provide a way for you to pay for any uncovered expenses on a pre-tax basis.

Always submit your claims to your primary insurance carrier and any out of pocket costs you may be paid for by your FSA.



5) Does that mean the FSA will pay my doctors for me?

No, you will have your own checkbook or debit card and you will need to make payment to the provider.



6) Are expenses that I paid with my FSA deductible on my tax return?

No, you get a deduction for what you deposit into the account so you cannot deduct it again.



7)How long is the FSA in effect for?

FSA’s will run calendar year and you must enroll every year and decide how much you will contribute to the plan. Your contributions generally cannot be changed during the year except in the instances below.

In the event of divorce or death of a spouse, you have the option to change your contribution at that time also.



8)What if I don’t spend all the money in the account? Can I use it next year?

No, unfortunately any unused money does not rollover into the next year. For this reason, you must be careful not to put too much into the account so you don’t waste any money.



9)I have unused money in my account. Where did it go?

If you did not spend your money before the end of the plan year,  the money gets forfeited to your employer and is under strict regulation by the IRS.



10) What else am I missing?

In addition to the use it or lose it rule, keep in mind that since your contributions are going in pre-tax, your future social security benefits may be affected.




11)Exactly what expenses can I reimburse myself for?

The IRS has a nice guide on FSA’s and what is eligible. I recommend reading through the guide. Additionally, they have removed some expenses from the eligibility list like over the counter prescriptions.

Publication 502 Medical and Dental Expenses

Publication 969 Health Savings Acccounts and Other Tax-Favored Health Plans

Information on changes to the FSA in 2011


 The list below was taken from Publication 502 and will link directly the the IRS webiste.