Medicaid expansion in Nevada
of Federal Poverty Level
Sandoval cited the fact that the federal government would be paying the vast majority of the costs as a primary motivator for expanding coverage, and noted that although he’s generally opposed to the ACA, he believes Medicaid expansion is the correct path.
Net enrollment in Medicaid/CHIP in Nevada had grown by more than 363,000 people from 2013 through 2020, which represented a 109 percent increase. Across the country, Medicaid/CHIP enrollment is on average 32 percent higher in 2020 than it was in 2013; this percentage includes the states where Medicaid has not been expanded.
Some of those people were already eligible for Medicaid before the eligibility guidelines were expanded. When Governor Brian Sandoval announced in 2012 that Nevada would expand Medicaid, the state expected about 70,000 already-eligible people to sign up. These are individuals who were eligible for Medicaid under the pre-expansion guidelines but who weren’t enrolled until the outreach efforts and individual mandate pushed them to get enrolled starting in 2014.
But the state also projected that only about 78,000 people would be newly eligible for Medicaid as a result of the expansion, and more than 200,000 were enrolled in expanded Medicaid within the first three years.
Medicaid managed care in Nevada
With the exception of aged, blind, and disabled enrollees, Nevada Medicaid enrollees living in urban Washoe County and urban Clark County are required to enroll in a Medicaid managed care plan. Kaiser Family Foundation reports that as of 2019, nearly three-quarters of Nevada Medicaid enrollees were covered under Medicaid managed care plans.
In late 2016, four carriers were chosen by the state to receive Medicaid managed care contracts. Two of them (Health Plan of Nevada, a UnitedHealthcare company, and AmeriGroup, an Anthem company) already had Medicaid MCO contracts in Nevada. Aetna Better Health of Nevada and Silver Summit Health Plan (Centene) were the two additional carriers that were selected to provide Medicaid managed care, although Aetna later reversed their decision and terminated their Medicaid managed care contract within weeks of the new coverage taking effect.
Nevada awarded additional points during the bidding process to MCO insurers that agreed to also offer private plans in the exchange, and all four insurers that won MCO contracts had agreed to offer exchange plans. But Aetna withdrew their plans to offer coverage in the exchange when they terminated their Medicaid managed care contract. Anthem also withdrew from the exchange, although they’ve continued to participate in the state’s Medicaid managed care program. State officials confirmed that the point spread between the insurers that won contracts and those that didn’t was significant enough that the winning insurers would have won even without agreeing to offer plans in the exchange. So Anthem’s exit from the exchange didn’t hamper their Medicaid managed care contract.
To allow Medicaid managed care enrollees to select from among the four managed care organizations that won contracts with the state for 2017, Nevada Medicaid held an open enrollment from April 1, 2017 through June 30, 2017, during which Medicaid enrollees could select the managed care organization that best fit their needs. People who enrolled in Aetna plans were switched to Silver Summit coverage as of September 2017.
As of 2020, Anthem, Health Plan of Nevada, and Silver Summit offer Medicaid managed care plans in Nevada.
The April-June enrollment period occurs annually, giving enrollees an opportunity to switch to a different Medicaid managed care insurer.
Nevada governor vetoed Medicaid-for-all; lawmaker vowed to re-introduce it in 2019 but resigned before that happened
In June 2017, Nevada’s legislature passed A.B.374 (by a vote of 12-9 in the Senate, and 27-13 in the Assembly). However, Governor Brian Sandoval vetoed it, saying that it left too many questions unanswered. In his veto message, Sandoval also expressed concern that the people who would have bought into the Medicaid program under A.B.374 might have been the population that’s already privately insured, rather than the uninsured population. Sandoval’s veto left the door open for something similar to A.B.374 in the future; he stated that “the ability for individuals to be able to purchase Medicaid-like plans is something that should be considered in depth.”
A.B.374’s primary sponsor, Democratic Assemblyman Mike Sprinkle, vowed to re-introduce similar legislation during the next session. Sprinkle was unopposed in the 2018 election, winning another term in Nevada’s Assembly. Nevada has legislative sessions in odd-numbered years only, so the issue was not readdressed in 2018 (although it started to gain traction in other states). Sprinkle proposed Medicaid buy-in legislation early in the 2019 legislative session but resigned soon after and the legislation was never formally introduced.
If A.B.374 had been signed into law, it would have allowed any uninsured Nevada resident to buy into Medicaid, under a program dubbed the Nevada Care Plan. Sarah Kliff has an excellent explanation of how the system would have worked, but in a nutshell, people would have been able to purchase coverage under the Nevada Care Plan via the exchange (Nevada Health Link, which uses HealthCare.gov for enrollment), just like any other health plan sold in the exchange.
ACA premium subsidies would have been used to offset the premiums for Nevada Care Plan. People who don’t qualify for premium subsidies would have had to pay full price for their coverage, but the assumption was that it would have been less expensive than private insurance. The details of the premiums would have been worked out at a later date if the legislation had been implemented, but Medicaid reimburses providers at lower rates than Medicare or private insurance, which makes the coverage less expensive.
The lower reimbursements also led to fewer providers accepting Medicaid (70.8 percent of doctors accepted new Medicaid patients, as opposed to 85.3 percent for Medicare and 90.0 percent for privately insured patients). But it’s important to keep in mind that there’s a national trend towards narrow provider network among private plans. So although private plans reimburse providers at higher rates, and doctors are more likely to accept new privately insured patients, members with private insurance are increasingly limited in terms of the scope of the provider network. In other words, even if 100 percent of providers are willing to accept new privately insured patients, the patients are still limited by the scope of their plan’s provider network, which might be quite restrictive.
As described above, most Nevada Medicaid enrollees are covered by managed care plans (the state contracts with private insurers to cover Medicaid members). The Nevada Care Plan would have also contracted with private insurers.
If the Medicaid buy-in approach had been signed into law by Gov. Sandoval, the state would have had to obtain a waiver from CMS in order to proceed, since Medicaid is a joint program between the state and federal government. The Trump administration has been encouraging states to take innovative approaches to health care reform, and may have agreed to the waiver as long as it didn’t increase federal costs for Nevada’s Medicaid program. The buy-in premiums would have designed so that they would be cost-neutral for the program, with enrollees’ aggregate premiums covering the cost of their care. But the lower rates that Medicaid pays to providers might have resulted in premiums that are more affordable than current private plans.
Governor pushed back against federal GOP efforts to repeal the ACA’s Medicaid expansion
Former Gov. Sandoval was the first Republican governor to commit to expanding Medicaid, and he was steadfast in his support for Medicaid expansion. Under the Trump administration, legislation to repeal the ACA nearly passed in 2017.
Sandoval was one of five Republican governors — in states that have expanded Medicaid — who pushed to keep Medicaid expansion intact or replace it with something very similar. He sent a letter to House Republicans in January 2017, noting that more than 400,000 Nevada residents had gained coverage as a result of the ACA, in large part because of Medicaid expansion.
Sandoval told lawmakers that while he agreed that states need “more choices, fewer federal mandates and the freedom and flexibility” to implement health care systems that work in each state, he implored House Republicans to “ensure that individuals, families, children, aged, blind, disabled and mentally ill are not suddenly left without the care they need to live healthy, productive lives.”
Nevada’s total Medicaid spending is about $6.4 billion, but the state only pays $1.1 billion of that; the rest is picked up by the federal government. For the population that was already eligible for Medicaid pre-ACA, the state pays a higher percentage of the cost than they do for the newly eligible population. For people who are newly eligible for Medicaid under the ACA, the federal government paid 100 percent of the cost through 2016; the federal share of the funding gradually decreased to 90 percent in 2020, where it will remain.
If Medicaid expansion had been repealed and replaced with something that cut federal funding below what the state currently receives, there were concerns that people would have lost coverage or benefits would have been cut. But GOP efforts to repeal or drastically change the ACA have so far not been realized.
Nevada Medicaid enrollment numbers
From the fall of 2013 through July 2020, total net enrollment in Nevada’s Medicaid program increased by 109 percent (most of this growth came early on; net enrollment was up 90 percent by early 2017). This is a much higher percentage increase than most states, and is second only to Kentucky where Medicaid enrollment has increased by 141 percent. The average growth in Medicaid across the U.S. during this per was 32 percent.
In addition to the newly eligible population, enrollment has been growing among people who were already eligible for Medicaid but had not enrolled prior to the start of the 2014 open enrollment (open enrollment only applies to private plans; Medicaid enrollment is year-round, but the publicity surrounding open enrollment since the ACA’s expansion of Medicaid has encouraged many Medicaid-eligible residents to seek coverage).
Nevada’s uninsured rate fell by 11.2 percent from 2010 to 2019, with expanded access to Medicaid played a significant role in decreasing the uninsured population. With the Covid-19 pandemic in 2020, uninsured rates have jumped significantly. Nevada’s uninsured rate in May 2020 was 21 percent.
Who is eligible for Medicaid in Nevada?
Medicaid in Nevada is available to the following legally present residents:
- Adults with household income up to 138 percent of poverty.
- Pregnant women with household income up to 165 percent of poverty.
- Children, depending on age, with household income up to 138 percent or 160 percent of poverty; all children are eligible for CHIP with income up to 200 percent of poverty.
How does Medicaid provide financial assistance to Medicare beneficiaries in Nevada?
Many Medicare beneficiaries receive Medicaid financial assistance that can help them with Medicare premiums, lower prescription drug costs, and pay for expenses not covered by Medicare – such as long-term care.
Our guide to financial assistance for Medicare enrollees in Nevada includes overviews of these programs, including Medicare Savings Programs, Medicaid long-term care benefits, and eligibility guidelines for assistance.
How do I enroll in Medicaid in Nevada?
- If you’re under 65 and don’t have Medicare, you can enroll online through HealthCare.gov. Or you can enroll online through Access Nevada (run by the Nevada Department of Health and Human Services). If you have an existing Access Nevada account that you created before November 10, 2014, you’ll need to go back to the site and create a new account with a new username and password.
- If you’re 65 or older or have Medicare, you can apply for Medicaid using this website.
- You can contact the Nevada Division of Welfare and Supportive Services at 1-800-992-0900 if you have questions (they make Medicaid eligibility determinations).
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.