OMNIA Health Plans
Our OMNIA℠ Health Plans give enrolled members the flexibility to use any hospital participating in our Horizon Hospital Network and any participating physician, other health care professional or ancillary provider participating in our Horizon Managed Care Network.
Features of our OMNIA Health Plans for individuals, families and groups:
- Primary Care Physician (PCP) selection is not required.
- Referrals are not required. Certain services/supplies do require prior authorization.
- OMNIA Health Plan members may use any physician or other health care professional from our broad Horizon Managed Care Network and any hospital from the Horizon Hospital Network, but will maximize their benefits and incur lower cost sharing when they use OMNIA Tier 1-designated physicians, other health care professionals, ancillary providers and hospitals.
- OMNIA Health Plans do not include out-of-network benefits. OMNIA Health Plan members must use physicians and other health care professionals who participate in the Horizon Managed Care Network and hospitals in our Horizon Hospital Network, except in cases of medical emergencies.¹
- OMNIA Health Plan members have coverage for eligible preventive services (physical exams, well-child care, immunizations, etc.) with no member cost sharing when these services are provided by a physician or other health care professional within the Horizon Managed Care Network.
¹OMNIA Health Plans offered to individual consumer, small employer, large group employers, National Accounts, Account Services Only (ASOs), Labor Accounts and Public Sector Accounts may include BlueCard® (out-of-area) coverage.
Click the links below to learn more about our OMNIA Health Plans.
- OMNIA Health Plan Product Information
- Participating Networks
- OMNIA Health Plans: Provider Tier Status
- PCP Selection
- Referrals
- Out-of-Network Benefits
- Deductibles
- Coinsurance
- Copayments
- Maximum Out-of-Pocket Limits
- Participating Physician Responsibilities
OMNIA Health Plan Product Information
Horizon BCBSNJ offers a variety OMNIA Health Plans both on and off the Health Insurance Marketplace. Though many aspects of these plans are standardized, there is often variety between plans. Please review the member's ID card carefully and access NaviNet for specific plan benefits.
Some OMNIA plans are qualified High Deductible Health Plans (HDHPs) and are compatible with or paired with a Health Savings Account (HSA).
OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options (including pharmacy benefits, BlueCard coverage and variations in out-of-pocket expenses).
Participating Networks
OMNIA Health Plan members must use physicians, other health care professionals that participate in the Horizon Managed Care Network and hospitals that participate in the Horizon Hospital Network.
OMNIA Health Plan members can incur lower cost sharing when they use OMNIA Tier 1 physicians, other health care professionals, hospitals and ancillary providers.
The OMNIA Health Plan tier status of physicians, other health care professionals, hospitals and ancillary providers may be reviewed on our Doctor & Hospital Finder.
OMNIA Health Plans: Provider Tier Status
All network hospitals and all physicians, other health care professionals and ancillary providers that participate in our broad Horizon Managed Care Network participate with our OMNIA Health Plans; however, OMNIA Health Plan members will incur lower cost sharing when they use OMNIA Tier 1-designated physicians, other health care professionals, hospitals and ancillary providers.
To make it easier for members to understand their cost sharing, all physicians and other health care professionals affiliated with, or who practice under or on behalf of a group practice, will participate with OMNIA Health Plans at the same tier when treating members under a particular group Tax ID Number (TIN).
For information on the evaluation criteria for the OMNIA Health Plans, please review our administrative policy, Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network.
Ancillary facilities and ancillary professionals that participate in our Horizon Managed Care Network will be designated OMNIA Tier 1. Some exceptions apply.
Access our Doctor & Hospital Finder to review physician tier-status designations for our OMNIA Health Plans.
PCP Selection
PCP selection is not required for members enrolled in OMNIA Health Plans.
Referrals
Referrals are not required for members enrolled in OMNIA Health plans.
Out-of-Network Benefits
OMNIA Health Plans do not include out-of-network benefits (except in the event of an emergency).
Deductibles
OMNIA Health Plans generally include two deductible amounts:
- OMNIA Tier 1 Deductible: Applies to services provided by participating Horizon Managed Care Network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 1.
- Tier 2 Deductible: Applies to services provided by participating Horizon Managed Care Network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 2.
The benefit designs of certain OMNIA Health Plans (e.g., certain Large Group Employer Plans) do not include a deductible for services provided by OMNIA Tier 1 providers.
Coinsurance
OMNIA Health Plans generally include two coinsurance rates:
- OMNIA Tier 1 Coinsurance: Applies to services provided by participating Horizon Managed Care Network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 1.
- OMNIA Tier 2 Coinsurance: Applies to services provided by participating Horizon Managed Care Network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 2.
Copayments
OMNIA Health Plans include different OMNIA Tier 1 and Tier 2 copayments for a number of services, including:
- Non-preventive services provided by a Horizon Managed Care Network PCP or specialist in an office setting
- Inpatient hospital care
- Inpatient behavioral health (mental health and substance abuse) care
- Emergency Room services
- Urgent Care Center services
- Outpatient behavioral health care
- Short-term physical, speech, occupational and/or cognitive therapy services provided in a freestanding office setting (limited to a combined 30 visits per calendar year)
- Therapeutic manipulation provided in an office setting (limited to 30 visits per calendar year)
Copayments for certain OMNIA Health Plans apply only after the OMNIA Health Plan member’s OMNIA Tier 1 or Tier 2 deductible is satisfied.
Maximum Out-of-Pocket Limits
OMNIA Health Plans include two separate maximum out-of-pocket (MOOP) limits:
- OMNIA Tier 1 MOOP—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 1.
- OMNIA Tier 2 MOOP—Applies to services provided by participating managed care network physicians, other health care professionals, ancillary providers and network hospitals that have been designated as Tier 2.
- Where there is an OMNIA Tier 1 deductible, any cost sharing such as copays, deductible and/or coinsurance expended in connection with an OMNIA Tier 1 covered charge shall also be credited to the Tier 2 deductible. Cost sharing for Tier 2 covered charges are not credited to the OMNIA Tier 1 deductible.
MOOP limits for OMNIA Health Plans for coverage types other than individual (i.e., family, two-adults, parent/child) include a component for each covered person as well as a “family” limit.
Participating Physician Responsibilities
Participating Network
OMNIA Health Plan members must use physicians and other health care professionals that participate in the Horizon Managed Care Network and hospitals that participate in the Horizon Hospital Network.
OMNIA Health Plan members incur lower cost sharing when they use OMNIA Tier 1 physicians, other health care professionals, hospitals and ancillary providers.
OMNIA Health Plan members have no out-of-network benefits (except in the event of an emergency).
Please use our Doctor & Hospital Finder to locate OMNIA Tier 1- and Tier 2-designated Horizon Hospital Networks and participating Horizon Managed Care Network physicians, other health care professional and ancillary providers.
Referrals
Based on the guidelines of our administrative policy,OMNIA Health Plan Tier Awareness, Horizon BCBSNJ requires that participating physicians and other health care professionals who are treating/coordinating the care of members and/or dependents enrolled in an OMNIA Health Plan discuss the cost sharing implications of using physicians, other health care professionals and facilities designated as OMNIA Tier 1 or Tier 2 with these patients (or their parents, guardians or designated personal representatives).
This conversation should be conducted at the time a determination to refer or recommend a patient to a physician, other health care professional and/or facility occurs and should be fully documented within the OMNIA Health Plan members/covered persons’ medical record.
The participating physician or other health care professional is responsible for retaining this information in the patient’s medical record and for making such documentation available, upon request by Horizon BCBSNJ, within 10 business days from the date of a request to review this information.
Review the Tier Awareness Policy.
Please use our Doctor & Hospital Finder to locate OMNIA Tier 1- and Tier 2-designated Horizon Hospital Networks and participating Horizon Managed Care Network physicians, other health care professional and ancillary providers.
