Nevada and the ACA’s Medicaid expansion

Nevada's Medicaid enrollment has grown by 95% since 2013. Governor vetoed Medicaid buy-in legislation

nevada Medicaid guide

Medicaid expansion in Nevada

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Nevada expanded Medicaid in 2014 under the guidelines laid out in the Affordable Care Act (ACA). As of late 2016, when Medicaid expansion had been effect for three years, CMS data indicated that 204,878 people were enrolled in expanded Medicaid in Nevada.

And net enrollment in Medicaid/CHIP in Nevada had grown by more than 314,000 people from 2013 through 2018, which represented a 95 percent increase (On average, across the country, Medicaid/CHIP enrollment is 27 percent higher in 2018 than it was in 2013, although that includes the 19 states where Medicaid had not been expanded as of 2018).

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. The bulk of the state’s population is in Washoe and Clark counties, and Kaiser Family Foundation reports that as of 2016, nearly 89 percent of Nevada Medicaid enrollees were covered under Medicaid managed care plans.

Four carriers were chosen by the state to receive Medicaid managed care contracts in late 2016. 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.

As of 2018, the other three insurers — Anthem, Health Plan of Nevada, and Silver Summit — are continuing to offer Medicaid managed care plans in Nevada.

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.

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 vows to re-introduce it in 2019

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). But on June 16, 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 only has legislative sessions in odd-numbered years, so the issue was not readdressed in 2018 (although it started to gain traction in other states). But it could be reconsidered in Nevada in 2019.

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 lead to fewer providers accepting Medicaid (68.9 percent of doctors accepted new Medicaid patients in 2013, according to the CDC, as opposed to 83.7 percent for Medicare and 84.7 percent for privately insured patients). But it’s important to keep in mind that there’s a trend towards narrow network HMOs, nationwide, 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 Governor 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

Governor Sandoval was the first Republican Governor to commit to expanding Medicaid, and has been 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 is gradually shrinking until it reaches 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 lose coverage or benefits would have been cut. House Republicans’ proposal to transition Medicaid to block grants or per-capita allotments would almost certainly have resulted in reduced federal funding. None of those things came to pass in 2017, and ACA repeal bills were not seriously considered in 2018. Democrats will have a majority in the US House starting in 2019, which should make the ACA safe from any repeal efforts for the time being.

Sharp increase in Nevada Medicaid enrollment

From the fall of 2013 through August 2018, total net enrollment in Nevada’s Medicaid program increased by 95 percent (most of this growth came early on; net enrollment was up 90 percent by early 2017, and the other 5 percent took another year and a half). This is a much higher percentage increase than most states, and is second only to Kentucky, where Medicaid enrollment has increased by 105 percent. Although people gain and lose eligibility for Medicaid throughout the year based on changing circumstances, the total Nevada Medicaid enrollment by March 2017 included an additional 298,568 people compared with late 2013.

Because Medicaid enrollment has increased so significantly in Nevada, there have been some concerns that newly-insured patients are finding it difficult to get timely appointments with healthcare providers.

Nevada’s uninsured rate also fell by nearly 40 percent from 2013 to 2015, going from 20.7 percent to 12.3 percent. The expanded access to Medicaid played a significant role in decreasing the uninsured population.

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 over the last few years has encouraged many Medicaid-eligible residents to seek coverage).

In 2012, roughly 88 percent of eligible children nationwide were enrolled in Medicaid or CHIP. In Nevada, that number was only 70.6 percent – among the lowest in the nation.  But the expansion of Medicaid and the publicity surrounding the ACA has helped to bump up Nevada’s total Medicaid enrollment by more than three-quarters in under three years.

Am I eligible?

As of 2016, 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 160 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 do I enroll?

  • 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.
  • 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).

As of 2014, nearly 87 percent of Nevada Medicaid enrollees were covered under Medicaid managed care plans. In Clark and Washoe counties, the state operates a mandatory Medicaid managed care program called the Nevada Mandatory Health Maintenance Program, which has been in place since 1998. Health Plan of Nevada and AmeriGroup currently have the Medicaid MCO contracts for NMHMP, but the contracts expire in mid-2017, and the state began rebidding them in late 2016.

First Republican governor to accept Medicaid expansion

Nevada’s Governor Brian Sandoval announced in December 2012 that the state would expand Medicaid starting in 2014. Sandoval was the first Republican Governor to commit to expanding Medicaid. Originally, this was an integral part of the ACA, but the Supreme Court ruled in 2012 that expansion was optional, and 19 states had not moved forward with Medicaid expansion as of late 2016.

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.


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.

How to apply in NV

Online through HealthCare.gov or through Nevada Health Link.  You can also enroll by phone at 800-318-2596.

Eligibility: The aged, blind, and disabled.  Also, coverage is available if your household income is up to 138% of poverty (about $16,105 for a single person).  For pregnant women, income can be up to 160%, and children are eligible for CHIP with household income up to 200% of poverty.

Nevada section