- Open enrollment for 2022 coverage started November 1, 2021, continues through January 15, 2022.
- Public option legislation signed into law in 2021; plans will be available as of 2026.
- 4.1% average proposed rate increase for Nevada’s exchange in 2022, and two additional insurers plan to join the marketplace (plus a look back at rate changes in prior years).
- Nevada residents now use Nevada Health Link (NOT HealthCare.gov) to enroll in health coverage.
- Off-exchange plans are now only available during open enrollment, as is the case in the rest of the U.S.
- Anthem (HMO Colorado/HMO Nevada) rejoined the exchange in Nevada for 2020, with plans available statewide.
- Enrollment in Nevada’s exchange grew each year through 2018, declined in 2019 and 2020, and then grew again for 2021.
- Insurer participation in Nevada’s exchange: 2014-2020 (including a look at how some areas of the state almost had no available plans for 2018).
- Association health plans available to some chamber of commerce members in Nevada.
- Short-term health plans can be sold in Nevada with initial plan terms of up to 185 days.
- Nevada’s approach to Medicaid managed care contracts has helped to keep insurers in the exchange.
Overview of the Nevada exchange
Since 2015, Nevada Health Link has been a state-run exchange using HealthCare.gov for enrollment. But the exchange began running its own enrollment platform as of the fall of 2019, so Nevada residents now use the Nevada Health Link website to buy coverage in the individual market.
Because Nevada runs its own exchange platform, they were able to offer a special enrollment period in 2020 for uninsured residents in response to the COVID-19 pandemic, during which more than 6,000 people signed up for coverage (HealthCare.gov did not offer a similar window, but nearly all of the other fully state-run exchanges did). Nevada Health Link was also able to extend its open enrollment period for 2021 coverage, due to the flexibility that goes with having a state-run exchange platform. And the exchange is also opening a COVID-related enrollment window for uninsured residents in 2021, running from February 15 to May 15, 2021.
Lawmakers in Nevada passed a bill in 2017 that would have allowed people in Nevada to buy into the state’s Medicaid program, but Governor Brian Sandoval vetoed that legislation. As described below, however, legislation is under consideration in 2021 that would create a public option program in the state as of 2026.
When can people enroll in health coverage in Nevada?
Open enrollment for 2022 coverage started November 1, 2021, with plans effective January 1, 2022. Nevada Health Link has announced that the enrollment window will continue through January 15, 2022.
Like the rest of the country, Nevada’s exchange offered a COVID/Amerian Rescue Plan enrollment window in 2021, which continued through August 15. During that window, more than 17,000 Nevada residents enrolled in coverage, with premium subsidies that were larger than normal, thanks to the American Rescue Plan’s subsidy enhancements.
Public option legislation enacted in 2021; plans will be available for 2026
Nevada S.B.420, signed into law in June 2021, calls for the state to create a public option health plan that would be available in the individual market as of 2026, and possibly also in the small group market. Medical providers who contract with the Nevada Medicaid program or the Nevada Public Employees’ Benefits Program will be required to also contract with the public option, and reimbursement rates will be “comparable to or better than” the amount that Medicare pays providers.
Stakeholders will meet to work out the details over the coming years, but the public option will include at least one silver-level plan and one gold-level plan that will be available through Nevada Health Link. Premiums for the public option plan will initially (as of 2026) be 5% lower than the benchmark plan premium (as of 2024, adjusted by the Medicare Economic Index), and the program will target a 15% reduction in premiums over the next four years.
Vox’s Dylan Scott interviewed Nevada Senate Majority Leader Nicole Cannizzaro about S.B420 prior to the passage of the bill; Cannizzaro explains the goals of the program and why it’s needed in Nevada. As has been the case with public option bills in other states, however, the idea is certainly not without controversy, and has drawn criticism from health care providers who worry that their reimbursement rates will be lower under the public option program.
Average proposed 2022 rate increase of 4.1% for Nevada exchange plans, plus two new insurers joining the exchange
In August 2021, the Nevada Division of Insurance published preliminary 2022 rate proposals filed by the state’s insurance companies. Seven insurers have filed proposals for plans that will be offered via Nevada Health Link, up from five in 2021. Aetna plans to enter the marketplace, as does Hometown Health Plan. They will join the five insurers that already offer plans through Nevada Health Link.
Hometown already offers plans in the state’s individual market, but only off-exchange; Aetna had previously offered off-exchange plans, and had intended to enter the marketplace in 2018 but scrapped that plan and exited the state’s individual market altogether at the end of 2017. As detailed below, Nevada’s exchange has had a tumultuous history in terms of insurer participation, with concerns in 2017 that there would be no participating insurers at all in some parts of the state for the coming year. But the market has stabilized since then. The seven insurers that plan to offer coverage in the exchange for 2022 will be a record high for Nevada’s exchange, in terms of insurer participation.
The insurers that plan to offer coverage through Nevada Health Link have proposed the following average rate changes, which amount to an overall increase of 4.1% (if finalized as proposed, without revisions):
- Health Plan of Nevada: 5% increase
- SilverSummit: 4% decrease
- HMO Nevada (HMO Colorado/Anthem): 8.4% increase
- SelectHealth: 3.5% decrease
- Friday Health Plans: 2.1% increase
- Aetna Health: New to the market, so no applicable rate change
- Hometown Health Plan: 12.2% increase (new to the exchange, but plans already exist off-exchange)
The Nevada Division of Insurance is reviewing the proposals and expects to have rates finalized by late August. The overall average rate increase for on-exchange plans in Nevada was 4.2%, so the proposals for 2022 are quite similar.
Rate changes in prior years
For perspective, here’s a look at how average premiums have changed over the years for plans sold in Nevada’s exchange (as always, these analyses refer to pre-subsidy rates; the changes in after-subsidy premiums can be very different):
2015: Average rate increase of 6.4%. The average rate changes ranged from a 6.9 percent decrease to a 24 percent increase.
2016: Average rate increase of 9.6%. But Anthem’s PPO option was new for 2016, and roughly a third of the exchange enrollees (who had coverage through the CO-OP or Time/Assurant in 2015) had to select coverage from a different carrier for 2016. For the remaining enrollees, the average premium increase within the exchange was 8.7% — but that’s assuming people didn’t shop around to find a better deal.
2017: Average rate increase of 10.6%. This was lower than the 15.02% that the carriers had initially requested. The overall average increase in Nevada ended up significantly lower than the national average of about 25%.
2018: Average rate increase of 36.8%. Two insurers offered plans in Nevada’s exchange for 2018. Silver Summit was new to the exchange for 2018, so there was no applicable rate change. Health Plan of Nevada, which was only available in Clark, Nye, and Washoe counties, increased their average premiums by 36.8 percent that year. Anthem had proposed a 62 percent average rate increase, but Anthem ultimately ended up withdrawing from the exchange at the end of 2017 (they’ve rejoined for 2020).
The rate increases for 2018 were based on the assumption that federal funding for cost-sharing reductions would not continue (the funding was ultimately terminated in October 2017). The additional cost to cover CSR was added to on-exchange silver plans in Nevada. For people who want silver plans but don’t receive a premium subsidy, off-exchange-only silver plans were available without the additional premium to cover CSRs, and there are also “extended” (expanded) bronze plans available (actuarial value of roughly 65 percent) that don’t have the CSR load included in their premiums. The expanded bronze plans use the new de minimus range (-4/+5) that applies to bronze plan actuarial value starting in 2018.
Health Plan of Nevada offered these extended bronze plans on and off-exchange in Clark, Nye, and Washoe counties. Silver Summit, the only on-exchange insurer in the rest of the state, did not offer any off-exchange-only plans in 2018, but there were other insurers that offered off-exchange-only plans, with a variety of silver and extended bronze plans available.
2019: Average rate decrease of 0.4% in the exchange, but a slight increase for entire individual market. The two exchange carriers initially proposed average rate changes of 5.2 percent for Silver Summit and 0 percent (no rate change) for Health Plan of Nevada. But Silver Summit revised their filing in August, requesting an average decrease of 1.1 percent, so the final approved weighted average rate change for Nevada’s exchange was a decrease of 0.4 percent. For Nevada’s entire individual market, including carriers that only offer plans outside the exchange, average rates increased by about 0.4 percent for 2019. At ACA Signups, Charles Gaba noted that the average rates in Nevada would likely have declined by about 5 percent in 2019 if the individual mandate penalty hadn’t been repealed, and if the Trump Administration hadn’t expanded access to short-term plans and association health plans.
2020: Average increase of 1.6% in the exchange; 1.9% outside the exchange. Three insurers offered plans in Nevada’s exchange for 2020: Health Plan of Nevada, SilverSummit, and HMO Colorado (HMO Nevada/Anthem BCBS). Their average approved rate increase was 1.6 percent.
HMO Colorado/HMO Nevada/Anthem offered coverage in Nevada’s exchange through 2017, but terminated their plans at the end of that year and did not offer coverage in 2018 or 2019. But their filing for 2020 noted that they would rejoin the exchange, statewide.
Sierra Health & Life, Hometown Health Plan (HMO), Hometown Health Providers (PPO), and Health Plan of Nevada offered plans in Nevada outside the exchange. Outside the exchange, the average rate increase for 2020 was 1.9 percent.
2021: Average increase of 4.2% in the exchange. In July 2020, the Nevada Division of Insurance published the average rate changes that insurers had proposed for 2021 (additional details here). At that point, the average proposed rate increase was 7.5%.
But by the time rates were finalized in late September, the average approved rate increase for the entire individual market (including off-exchange insurers) was 4.4 percent. On-exchange, the average approved rate increase for 2021 was 4.2 percent.
Two new insurers entered Nevada’s marketplace for 2021. Friday Health Plans, a Colorado-based company, is offering 2021 coverage statewide in Nevada’s exchange. And SelectHealth, which already offered individual market coverage in Utah and Idaho, is offering plans in Clark and Nye counties for 2021. There are a total of 50 plans available through Nevada Health Link for 2021, up from 27 that were available for 2020.
Outside the exchange, there are also plans available in 2021 from Sierra Health & Life, Hometown Health Plan, and Hometown Health Providers. Across all off-exchange plans in Nevada, the average approved rate increase for 2021 is 5 percent (note that Hometown Health Plan is joining the exchange for 2022).
Off-exchange plans no longer available year-round
The ACA created an open enrollment period for individual major medical health plans. State-run exchanges have the option to adjust the timing of the annual enrollment window, but all states have a limited enrollment window. And in every state except Nevada, that enrollment window has applied to plans purchased outside the exchange, just as it applies to plans purchased via the exchange.
But from 2014 through 2019, Nevada law required plans sold outside the exchange to be available for purchase year-round, with a waiting period of up to 90 days before the coverage would take effect. But Section 56 of Nevada SB482, enacted in 2019, eliminated the requirement that health plans be available year-round outside the exchange. The law took effect October 1, 2019, bringing Nevada’s rules into line with the rest of the country: Both on-exchange and off-exchange, individual major medical plans can only be purchased outside of open enrollment if the applicant has a special enrollment period triggered by a qualifying event.
The transition from HealthCare.gov to a fully state-run exchange platform
In 2014, Nevada ran its own exchange, which was fraught with technological problems. The following year, Nevada switched to using HealthCare.gov’s enrollment platform, but the kept the rest of the state-run exchange (Nevada Health Link) in place, retaining a significant amount of autonomy. That setup remained in place through 2019, but Nevada has now switched back to running its own exchange, including the enrollment platform.
The new system was live as of September 2019, and Nevada residents who were enrolled in 2019 coverage through HealthCare.gov were able to claim their account on Nevada Health Link’s site. Access codes for this process were emailed or mailed (depending on the consumer’s preference) in early September. Consumers who can’t find their code or didn’t receive one can call 1-800-547-2927 for assistance. Window shopping for 2020 plans was enabled in early October, and enrollment began November 1.
Enrollment in 2020 health plans in Nevada ended December 15, 2019 (people who began by that date were given until December 20 to finish the application process). This is the same schedule that HealthCare.gov used for the previous two years, so Nevada residents were already accustomed to the December 15 deadline. As noted above, Nevada Health Link opted to extend open enrollment for 2021 plans by a full month.
The transition back to a fully state-run exchange: A history
There’s no legislative session in even-numbered years in Nevada, but in February 2018, the Nevada Legislature’s Interim Finance Committee approved $1 million in funding for Nevada Health Link to transition back to using its own website for enrollment, rather than HealthCare.gov, starting in the fall of 2019.
On March 19, 2018, Nevada Health Link issued a Request for Proposal, seeking bids from vendors who would create “an integrated online health insurance exchange technology platform and associated consumer assistance center,” which would be up and running by the fall of 2019, in time for the start of the seventh open enrollment period. Vendors had until early-April 2018 to submit bids. In May, the exchange unanimously selected GetInsured (VIMO Inc.) as the vendor that would orchestrate the transition to a fully state-based exchange, and manage the call center for the Nevada exchange (instead of using HealthCare.gov and the federal call center). The exchange anticipates that the transitional will reduce technology operating costs by about 50 percent — from $12 million a year to about $6 million a year.
GetInsured also handled Idaho’s successful transition from HealthCare.gov to a state-run exchange platform prior to the 2015 plan year, and currently operates exchange platforms in six states (California, Connecticut, Idaho, New Mexico, Mississippi, and Washington).
The federal government charged states like Nevada, that have state-run exchanges but use the HealthCare.gov enrollment platform, a fee equal to 2 percent of premiums in 2018. The government increased that fee to 3 percent in 2019 (the fee in states that rely fully on the federally-run exchange is 3.5 percent), although it dropped down to 2.5 percent starting in 2020. Nevada Health Link charges a fee of 3.15 percent as of 2020, but has noted that this might be reduced in future years if the savings from the transition to a fully state-run exchange would make it sustainable to do so. The exchange uses the revenue from the fee to fund its own outreach and enrollment operations. Prior to 2020, most of the fee was used to pay for the HealthCare.gov services.
Nevada’s exchange leadership is confident that a new state-run enrollment platform, using updated technology, will be much less expensive than paying a fee equal to 2.5 percent of premiums in order to continue using HealthCare.gov (the current estimate is that it will cost about 1.5 percent of premiums to operate the new state-run exchange platform, as opposed to 2.5 percent if they were to continue to use HealthCare.gov). In addition, the state will have increased access to demographic data about exchange enrollees, which will enable them to better target their marketing and outreach in future years. And the state hopes the new and improved enrollment platform will create a “better user experience” for consumers, insurers, and enrollment assisters, including brokers and navigators.
Enrollment in Nevada’s exchange: 2014 – 2021
Enrollment in Nevada’s exchange started out particularly low, given the exchange’s technical troubles in the first year. It grew substantially over the next few years, but declined in both 2019 and 2020. It increased again in 2021, back to nearly the level it had been at in 2019. Here’s a look at enrollment in private plans over the years (this does not count Medicaid enrollments through the exchange):
2014: Nevada Health Link extended its 2014 open enrollment period to May 30 for people who experienced technical difficulties during the regular enrollment period. A total of 45,390 people enrolled in private plans through the exchange — still short of their goal of 50,000 (which had been modified in early 2014, down from an original goal of 118,000).
2015: For 2015, everyone had to re-enroll from scratch, since Nevada was using the Healthcare.gov platform for the first time during the 2015 open enrollment period. But with a much better website, enrollment grew to 73,596 people for 2015.
2016: Enrollment in the Nevada exchange reached 88,145 for 2016. The process of renewing coverage for 2016 was much easier than it was for 2015; auto-renewal was available, and plan changes could be made by just logging back into an existing exchange account.
2017: The Nevada exchange ran an extensive marketing and outreach campaign leading up to the start of open enrollment for 2017 coverage. Enrollment grew by about 1 percent in 2017, with 89,061 people enrolled in private plans for 2017 through the Nevada exchange. This enrollment growth was in contrast with the average across all states that use HealthCare.gov, where average enrollment was down about 5 percent in 2017.
2018: The Nevada exchange once again ran an extensive outreach and marketing campaign before and during open enrollment for 2018 coverage, and enrollment continued to increase. 91,003 people enrolled in coverage through Nevada’s exchange during the open enrollment period for 2018 coverage. Nevada’s enrollment growth did not mirror the national trend, which saw enrollment in the majority of the states — especially those that use HealthCare.gov — peaking in 2016 and declining each year thereafter.
2019: Year-over-year enrollment declined in 2019, for the first time in Nevada Health Link’s history. 83,449 bought private plans during open enrollment, which was about 8 percent lower than it had been in 2018. Across all states that use HealthCare.gov, enrollment was down about 4 percent for 2019, due to a variety of factors, including the elimination of the individual mandate penalty for 2019 and the expansion of short-term plans and association health plans as alternatives to ACA-compliant individual market coverage.
2020: Enrollment declined again in 2020, with 77,410 people signing up for individual health coverage during open enrollment.
2021: Enrollment grew to 81,903 people during the open enrollment period for 2021 health plans. And more than 17,000 people enrolled during the COVID/American Rescue Plan enrollment window, which continued through August 15, 2021.
Insurer participation in Nevada’s exchange: 2014 to 2020
2014: Four insurers. In the first year the exchange was operational, plans were available from Anthem, Health Plan of Nevada (UnitedHealthcare), Nevada Health CO-OP, and Saint Mary’s Healthfirst.
2015: Five insurers. Assurant (Time) joined the exchange for 2015, bringing the total number of insurers to five: Anthem, Assurant, Health Plan of Nevada, Nevada Health CO-OP and Prominence Health Plan (formerly Saint Mary’s Healthfirst).
2016: Three insurers. In late August 2015, the Nevada Health CO-OP (which had 37 percent of the exchange’s market share in 2014) announced that they would cease operations at the end of the year. Existing members had to pick a plan from another insurer in order to continue to have coverage in 2016.
The Nevada Health CO-OP’s Board voted voluntarily to shut down, as opposed to CO-OPs in Iowa/Nebraska, Arizona, Colorado, and New York, which were shut down by state and federal regulators. And while 12 of the original 23 CO-OPs had closed by the end of 2015, most of them did so after the federal government announced that risk corridor payments would be only a fraction of what was owed; Nevada Health CO-OP announced their closure more than a month before the risk corridor shortfall was known.
Assurant (Time) also announced earlier in 2015 that they would be exiting the individual market nationwide, and would not participate in the 2016 open enrollment. Both the CO-OP and Assurant had requested double-digit rate increases for 2016, but their members ended up having to select a plan from a different carrier for 2016.
Anthem began offering PPO options in the exchange for 2016 (they only had HMO options in 2015). In addition, Prominence expanded their plan offerings into Southern Nevada. Humana also joined the exchange for 2016, but only in the small-group market.
2017: Three insurers. Unlike many other states, carrier exits were not in the headlines in Nevada in the fall of 2016, as the carriers that participated in the exchange in 2016 all continued offering coverage for 2017. Anthem was the only insurer that offered exchange coverage in all 16 Nevada counties in 2017. Plans were also available from Health Plan of Nevada (UnitedHealthcare) and Prominence.
UnitedHealthcare exited the individual markets at the end of 2016 in most of the states where they offered exchange plans in 2016. But they remained in the Nevada market, both on and off-exchange (they only continued to participate in three exchanges: Nevada, Virginia, and New York). United’s HMO (Health Plan of Nevada) was available through the exchange, but they also have a PPO (Sierra Health and Life) that’s available off-exchange. Health Plan of Nevada was only available in three counties (Nye, Clark, and Esmerelda), but 90 percent of Nevada’s exchange enrollees live in those three counties. Prominence served seven counties, including Nye and Clark. So in those two counties, there were plans available in 2017 from all three insurers.
2018: Two insurers. Nevada created plenty of headlines in 2017. Prominence exited the ACA-compliant individual market in Nevada at the end of 2017. And with the exception of off-exchange catastrophic plans, Anthem discontinued all of their ACA-compliant individual market plans at the end of 2017, and did not offer any plans in the exchange in 2018.
Initially, Anthem’s plan was to continue to offer HMO plans in the exchange in Clark, Nye, and Washoe counties, and a catastrophic plan statewide outside the exchange. Anthem had proposed a 62 percent average rate increase for their remaining plans. But in early August, the Nevada Division of Insurance announced that Anthem had decided to withdraw completely from the Nevada exchange. [Note that this decision didn’t change the number of “bare” counties in Nevada; there were already 14 counties that didn’t have any exchange insurers lined up for 2018 — due to Anthem’s earlier decision to limit coverage to just three counties — and that was still the case with Anthem’s exit.] Anthem also exited the exchange in Virginia, Ohio, Indiana, and Wisconsin at the end of 2017, and scaled back their participation in Georgia and California.
Health Plan of Nevada continued to offer coverage only in Nye, Clark, and Esmerelda counties, but with the announcement that Anthem and Prominence would exit the exchange at the end of 2017, there were no insurers lined up to offer coverage in 14 of the state’s 17 counties for 2018. This sounded worse than it was, since the vast majority of Nevada’s population is in Clark and Washoe counties. But for roughly 8,000 people who buy their own insurance in the 14 “bare” counties — which are mostly rural but include Carson City, with a population of 54,000 — the situation appeared dire.
Two additional insurers — Aetna and Silver Summit/Centene — had filed plans for 2018, but the filings were initially limited to Clark, Nye, and Washoe counties. But Aetna reversed course and decided in the summer of 2017 that they would not offer plans in Nevada’s exchange after all (and they also exited the off-exchange market at the end of 2017). This came on the heels of Aetna’s announcement that they had terminated their new Medicaid managed care contract in Nevada (the managed care contract called for Aetna to offer plans in the exchange — details below — but once the managed care contract was terminated, Aetna was free to withdraw their exchange plan filings, which they did).
The Nevada Division of Insurance explained that Aetna had experienced lower-than-expected enrollment in their new Medicaid managed care plan, and had thus decided to terminate the contract. Aetna noted that they could not “support a sustainable business” with the level of Medicaid managed care enrollment that had received. Since the reason they were planning to offer private plans in the exchange for 2018 was due to the Medicaid managed care contract, they withdrew those plans as well. [Aetna had completely eliminated their exchange participation nationwide as of 2018.]
But Nevada regulators continued to reach out to insurers in an effort to fill the bare counties, and their efforts were successful when Centene (Silver Summit) agreed to offer coverage in all 14 counties for 2018.
A press release from Governor Sandoval’s office included comments from various stakeholders in Nevada. Heather Korbulic, who was then the executive director of Nevada’s exchange, said “We are grateful that SilverSummit has stepped up to the plate, offering relief to thousands of residents who thought they would be deprived of access to health insurance. Thanks to Governor Sandoval’s tireless and unwavering commitment to ensuring access to health care for all Nevadans, individuals throughout the state will have access to qualified health plans.”
[It’s notable that this was the case in all of the potentially bare counties that popped up around the country during the rate filing process in mid-2017. Washington, Tennessee, Indiana, Kansas, Missouri, Ohio, Virginia, and Wisconsin were all facing potentially bare counties for 2018, but insurers — in many cases, Centene — stepped up to fill them. The vast majority of the counties in the US were never facing a dearth of insurers in the first place, and all of those that were facing bare areas were ultimately covered before the start of open enrollment.]
2019: Two insurers. Silver Summit/Centene continued to offer statewide coverage in 2019. They offered four plans in 2018, and that increased to six plans in 2019. Health Plan of Nevada also continued to offer exchange plans in 2019.
Anthem terminated all of their grandfathered plans in Nevada on December 31, 2018 (Nevada did not permit grandmothered/transitional health plans to be renewed after 2013). So in 2019, Anthem’s only individual market plans were off-exchange catastrophic plans. (as described below, however, Anthem partnered with the Las Vegas Chamber of Commerce to offer association health plans in Nevada).
2020: Three insurers. HMO Colorado (HMO Nevada/Anthem BCBS) rejoined the Nevada exchange for 2020, offering plans statewide. Silver Summit and Health Plan of Nevada also continued to offer plans in the exchange, giving people in some areas (Washoe, Clark, and Nye counties) three insurers from which to choose.
2021: Five insurers. The three existing insurers will remain in the exchange, and will be joined by two newcomers: Friday Health Plans (statewide) and SelectHealth (Clark and Nye counties).
Association health plans
In August 2018, the Nevada Division of Insurance announced that they had received their first association health plan filing, for the Boulder City, Henderson, and Latin Chambers of Commerce. The plans, which are fully insured by Health Plan of Nevada (UnitedHealthcare) — ie, these are not self-insured plans — became available to members of those chambers of commerce with 1-50 employees as of September 1, 2018 (sole proprietors are limited to an annual open enrollment period that runs for one month and starts June 1 each year, so the first open enrollment window for sole proprietors will be June 2019). Members can select from among 10 different plan options, all of which cover maternity care, mental health care, and prescriptions.
These are the three essential health benefits that critics have been most concerned about with the expansion of association health plans, as they’re the three that are most likely to be excluded in cut-rate plans. Short-term health insurance plans, for example, often exclude coverage for those three benefits. Under the new rules that apply to association health plans, the plans are regulated under large group rules, rather than the more stringent small group rules. Large group plans are not required to cover the essential health benefits (with the exception of preventive care, which must be covered on all non-grandfathered large group plans). But for now, it appears that the first set of new association health plans in Nevada are fairly comprehensive.
In September 2018, the Nevada Division of Insurance announced that two more chambers of commerce — Reno-Sparks Northern Nevada’s Chamber of Commerce and the Las Vegas Metro Chamber of Commerce — had filed plans for fully insured association health plans. The Reno-Sparks Chamber plan, offered in a partnership with Prominence Health Plan, became available for coverage as of December 1, 2018. The Las Vegas Chamber’s plan, offered in a partnership with Anthem, is available to chamber members statewide.
In addition to the various Chamber of Commerce plans, the Nevada Contractors and Nevada Builders Alliance associations, and the Builders Association of Northern Nevada are offering association health plans to their members.
In March 2019, a federal judge invalidated the Trump Administration’s new association health plans rules, but only insofar as they allowed sole proprietors and unrelated small businesses to enroll. As of mid-April, however, Health Plan of Nevada confirmed that nothing had thus-far changed for the Henderson Chamber’s plan, and they were still expecting sole proprietors to be able to enroll in the plan in June. As of late 2019, the Reno-Sparks plan indicated that it was only available to businesses with 2-50 employees, but the Boulder City Chamber plan does still say that it’s available to sole proprietors who don’t have employees.
State’s approach to MCOs bolstered insurer participation in exchange, albeit only in metropolitan areas
The entry of Silver Summit (and Aetna’s erstwhile plans to enter the exchange) to the exchange in 2018 was linked to the state’s process for approving Medicaid managed care contracts. Prior to 2017, Nevada required its Medicaid Managed Care vendors (MCOs) to offer at least one silver and one gold plan in the state’s exchange. In other words, access to Medicaid Managed Care business was not available for carriers that opted not to participate in the exchange. Anthem (AmeriGroup) and United (Health Plan of Nevada) both operated Medicaid Managed Care plans in Nevada prior to 2017, and offered plans in the exchange.
For 2017, the state decided to allow four Medicaid MCOs instead of just two (although with Aetna’s exit, they dropped to three). And while they eliminated the requirement that Medicaid MCOs also offer QHPs in the exchange, the Nevada Division of Insurance reported that during the process of selecting MCOs, the state added five additional points to the scores of insurers that indicated on their MCO proposal that they would also offer QHPs in the exchange (MCO contracts are awarded to the insurers that get the highest scores).
The Division of Insurance confirmed in early May that they expected all four of the state’s MCOs — Anthem, United, Silver Summit, and Aetna — to file rates and plans for 2018 QHPs that will be sold in the exchange, as a result of the information submitted during the MCO bidding process (note that Prominence, which exited the exchange at the end of 2017, did not have an MCO contract in Nevada).
But Aetna subsequently terminated their MCO contract and withdrew their exchange plans, and Anthem withdrew their exchange plans. I reached out to the Nevada Department of Health and Human Services to better understand Anthem’s position, which was to retain their Medicaid managed care contract, but exit the Nevada exchange. Basically, because it wasn’t mandatory for insurers to offer exchange plans, there was some wiggle room in the MCO contracts. And it turns out that the additional points for exchange participation weren’t really a significant factor after all. There were seven insurers that bid for MCO contracts, and there was enough of a point spread between the four insurers that won MCO contracts and the three that didn’t, that the four that won would have won even if they hadn’t received the additional five points for agreeing to offer exchange plans.
So essentially, Anthem would have won an MCO contract even if they hadn’t agreed to offer plans in the exchange, which is why their exit from the exchange didn’t hamper their MCO contract. This would also have been the case for Aetna, but as described above, their decision to terminate their MCO contract was made based on their initial MCO experience, rather than issues with entering the exchange.
United filed plans to continue to offer QHPs in Nevada’s exchange for 2018, and they did the same thing in New York, where a new regulation bars insurers that drop out of the exchange from participating in Medicaid managed care, Child Health Plus, or the state’s Essential Plan. Virginia is the only other state where United offered plans in the exchange in 2017, and they exited Virginia’s exchange at the end of the year. So the only states where United continued to offer exchange coverage in 2018 are states that have linked Medicaid managed care participation to participation in the exchange (United ended up having to rejoin the exchange in Massachusetts in 2019, also due to state rules).
The MCO contract bidding process indicated an effort on Nevada’s part to keep insurers in the exchange, and likely played a role in Silver Summit’s entry to the exchange and the preservation of insurer choice for most Nevada residents in 2018. However, there’s clearly an issue with localized versus statewide coverage. Rural areas have always been less attractive to insurers, and the extra points that Nevada awards to its MCO bidders who offer exchange plans does not require that those plans be available statewide. Silver Summit agreed to offer coverage in the rural areas in order to alleviate the bare county problem that Nevada was facing, but they were not required to do so.
Nevada is considering expanding their MCO contracts to be statewide, and are also considering the possibility of reverting to their previous system of requiring MCO insurers to offer products in the exchange (rather than simply offering bonus points during the MCO bidding process).
No grandmothered plans in Nevada
Nevada’s Division of Insurance announced in late November 2013 that policies scheduled to end on December 31 could not be extended into 2014, and should instead be replaced with ACA compliant plans. Thus there was also no renewal available for pre-2014 plans heading into 2015, and all non-grandfathered plans in the individual market in Arizona are now ACA-compliant.
History of the Nevada exchange
Nevada’s blueprint for its state-run health insurance exchange received federal approval on Dec. 3, 2012. Gov. Sandoval and the state legislature created the Silver State Health Insurance Exchange in 2011, and the state moved steadily to get the marketplace up and running.
Nevada Health Link operates as a “free market facilitator” or “clearinghouse,” meaning it allows all qualified health insurance companies to sell policies on the exchange.
Nevada had contracted with Xerox to build the state’s exchange platform, but the system never worked correctly (the IRS allowed an exemption from the individual mandate penalty for 2014 for Nevada residents who were unable to complete the enrollment process due to flaws in the exchange).
On May 20, 2014, the exchange board unanimously voted to drop Xerox and switch to Healthcare.gov instead. Xerox had been paid about $12 million of the $72 million that had been allocated to build the exchange, but it was determined that they would only receive a small portion of the remaining funds, since much of the site was never built or was not built correctly. However, Xerox continued to work with Nevada Health Link until April 2015, running call centers and enrolling applicants who qualified for a special open enrollment period during the latter part of 2014.
Things went much better for Nevada Health Link during the second open enrollment period, since they were using Healthcare.gov as their enrollment platform. The state retained some responsibilities and was still legally be classified as a state-run exchange.
With Nevada Health Link relying on the now very-functional Healthcare.gov site for eligibility and enrollment, the state-run portion of the exchange was able to focus on consumer advocacy and assistance, without being bogged down by the technical problems that hampered the exchange during the 2014 open enrollment. The state launched its new and improved Nevada Health Link website on November 3, 2014.
In addition to using Healthcare.gov for enrollment, premium payments began to be handled directly by the carriers in 2015, rather than routing through the exchange first. As a result of these changes, Nevada Health Link had far fewer technological headaches during the 2015 open enrollment and throughout the year.
The federally-supported state-based exchange model was used from 2015 through 2019, but Nevada has transitioned back to a fully state-run exchange as of the fall of 2019. People enrolling in coverage for 2020 used Nevada Health Link’s enrollment platform and call center, and the state no longer relies at all on the federally-run exchange. FAQs about the transition back to a fully state-run exchange are available here.
More Nevada health insurance exchange links
Silver State Health Exchange
Information about exchange planning and start-up operations
State Exchange Profile: Nevada
The Henry J. Kaiser Family Foundation overview of Nevadaʼs progress toward creating a state health insurance exchange.
Nevada Governorʼs Office for Consumer Health Assistance
Serves all residents with health-related issues; benefits, denials, insured, uninsured, worker’s compensation, and hospital billing.
(702) 486-3587 / Toll-Free: 1-888-333-1597 (nationwide)