Highlights and updates
- Silver Summit will cover all 14 counties that would have been bare
- Anthem withdrawing from Nevada exchange at end of 2017
- Two insurers will offer 2018 coverage; 1 new and 1 returning
- Average proposed rate increase of 27% for remaining insurer
- Off-exchange plans available year-round with a waiting period
- Medicaid contracts loosely tied to exchange participation
Overview of the Nevada exchange
Nevada Health Link is a state-run exchange that uses Healthcare.gov for enrollment (there are five states in 2017 that have state-run exchanges but use HealthCare.gov for enrollment: Arkansas, Kentucky, Nevada, New Mexico, and Oregon).
The Nevada exchange ran an extensive marketing and outreach campaign leading up to the start of open enrollment for 2017 coverage. They also saw a slight enrollment increase for 2017, instead of the declining enrollment that was typical in HealthCare.gov states.
Nevada is also the only state in the country where off-exchange plans are available year-round, albeit with a three-month waiting period before coverage begins if you enroll outside of open enrollment and don’t have a qualifying event.
Open enrollment for 2018 coverage will run from November 1, 2017, to December 15, 2017. This is a shortened timeframe, new for this year, and applies nationwide. All plans purchased during open enrollment will take effect January 1, 2018.
With Silver Summit’s expanded coverage area, all counties will have coverage in 2018
90 percent of the exchange enrollees in Nevada are able to select from among three different carriers in 2017. 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 have all continued offering coverage for 2017. This includes UnitedHealthcare, which only remained in three exchanges for 2017 — Nevada being one of them.
But Nevada created plenty of headlines in 2017. 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 sounds worse than it was, since the vast majority of Nevada’s population is in Clark and Washoe counties, both of which (along with Nye County) still had insurers slated to offer coverage. But there for 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.
But Nevada regulators continued to reach out to insurers in an effort to fill the bare counties. The Nevada Division of Insurance noted in an August 7 press release that they are “working with [their] state partners on a plan to help consumers shop the Exchange market at open enrollment for the 2018 Plan Year and remain optimistic that there will be coverage for consumers on the Exchange throughout the state.”
And their efforts were successful. Centene (Silver Summit) has agreed to offer coverage in all 14 counties. As a result, all Nevada residents will now have at least one insurer from which to choose when open enrollment begins on November 1.
A press release from Governor Sandoval’s office included comments from various stakeholders in Nevada. Heather Korbulic, 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.”
And Nevada Insurance Commissioner, Barbara D. Richardson, said “We appreciate that such an experienced insurance carrier will be joining the Nevada Exchange. The Division continues to work with our state partners to explore long-term solutions for Nevada citizens.”
It’s notable that this has been the case in most of the bare counties that have popped up around the country over the last few months. Washington, Tennessee, Indiana, Kansas, and Missouri were all facing bare counties earlier in the summer, but insurers have stepped in to fill them. Ohio had 20 bare counties and is now down to one, and there’s one in Wisconsin. The vast majority of the counties in the US were never facing a dearth of insurers in the first place, and nearly all of those that were have now been filled (notably, Centene has been the insurer that filled quite a few of the bare counties, just as they’re doing in Nevada).
Proposed rates and plans for 2018
There are two insurers that will offer plans in the Nevada exchange for 2018: SilverSummit and Health Plan of Nevada (UnitedHealthcare). Silver Summit will be the only available option in most rural areas.
- Silver Summit will be new to the exchange for 2018, so there’s no applicable rate change.
- Health Plan of Nevada has proposed a 27.24 percent average rate increase for 2018, with a range of 19 percent to 36 percent, depending on the plan. The rate change proposal is under review by Nevada regulators.
Silver Summit currently only offers Medicaid/CHIP (Check Up) plans in Nevada, but they confirmed by phone in May that they would be filing exchange plans for 2018. Silver Summit is a subsidiary of Centene, and the insurer announced in June that in addition to Nevada, they will also be joining the exchanges in Missouri and Kansas for 2018, and expanding their existing coverage area in several other states.
In a late June press release about the proposed rates (before Anthem and Aetna withdrew their exchange filings), the Nevada Division of Insurance noted that “the proposed rate increases on the rate submissions filed with the Division reflect the uncertainty of the health care market,” which presumably means that at least some of the proposed rate increase for Health Plan of Nevada is due to the uncertainty in terms of whether cost-sharing redutions will continue to be funded, and whether the individual mandate will continue to be enforced.
Anthem had proposed a 62 percent average rate increase, but state regulators announced in early August that Anthem had opted to withdraw from the exchange altogether (details below).
Aetna & Silver Summit joined for 2018, but Aetna soon withdrew plan filings after terminating Medicaid managed care contract
The rate filing deadline for 2018 plans in Nevada was May 17, 2017 if the insurer is new to the QHP market, and June 12 if the carrier already has QHPs for sale in the market. There are currently exchange plans available in Nevada from Health Plan of Nevada (UnitedHealthcare), Prominence, and Anthem Blue Cross Blue Shield (both HMO and PPO entities). Anthem is the only insurer that offers plans statewide in 2017.
Two additional insurers — Aetna and Silver Summit — filed plans for 2018. But the filings were initially limited to Clark, Nye, and Washoe counties (these include Reno and Las Vegas). Then in July, Nevada freelance reporter, Pashtana U., reported that Aenta had withdrawn their filings, and would not offer plans in the Nevada exchange in 2018. 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).
Aetna’s Medicaid managed care contract in Nevada was new in 2017, and they began covering members as of July 1. Their decision to terminate their managed care contract came just a few weeks later. 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.
On May 10, Aetna announced that they were exiting the exchanges where they currently offer plans at the end of 2017, and said that Aetna “at this time has completely exited the exchanges.” Their short-lived plan to participate in Nevada’s exchange was announced in June, and at that point, Nevada was the only state where Aetna was planning to offer exchange plans. Their subsequent decision to withdraw their Nevada exchange plans means that they will not have an exchange presence anywhere in the country in 2018.
Prominence, which currently offers coverage in seven Nevada counties, announced in late June that they will exit the ACA-compliant individual market at the end of 2017.
Anthem initially planned to reduce exchange coverage area to 3 counties, but later opted to withdraw completely
Also in late June, Anthem announced that they would significantly reduce their Nevada exchange coverage area in 2018 (Anthem is the only Nevada insurers that offers statewide coverage in the exchange in 2017). At that point, their 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. They will continue to offer a catastrophic plan statewide outside the exchange, but will not have any exchange options available when open enrollment begins on November 1. [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’s grandfathered plans (in effect before the ACA was signed into law) are not impacted, and neither are employer-sponsored plans. It’s only their ACA-compliant individual market plans that will be terminated at the end of 2017 in Nevada. Anthem is also exiting the exchange in Virginia, Ohio, Indiana, and Wisconsin at the end of 2017, and scaling back their participation in Georgia and California.
The result of the announcements by Anthem and Prominence (before Silver Summit agreed to expand into the rural areas of the state) was that 14 counties in Nevada had no insurers currently slated to offer coverage in the exchange. There are about 8,000 people whose coverage was in jeopardy before Silver Summit stepped up (Nevada’s exchange enrolled more than 89,000 people for 2017, but the majority of them are in Clark and Washoe counties and were never in danger of not having coverage options in 2018).
Anjeanette Damon, a reporter for the Reno Gazette-Journal, tweeted in June that Nevada Insurance Commissioner Barbara Richardson had indicated that insurers could offer coverage in the rural areas of the state in 2018, but that the premiums would be so high that nobody would be able to afford them. For people who are ineligible for ACA premium subsidies (because their income is over 400 percent of the poverty level, a threshold that starts that $48,240 for a single person in 2018, and $98,400 for a family of four), that could very well be true.
But for people whose income doesn’t exceed 400 percent of the poverty level, ACA premium subsidies have no upper limit on how large they can be. Alaska is a good example of how this works: Premiums in Alaska are far higher than the US average, but average premium subsidies are nearly twice as big in Alaska to compensate. If insurers were to agree to offer exchange coverage in those other 14 Nevada counties in 2018, they could charge whatever they needed to charge (as long as it’s actuarially justified by claims data), and premium subsidies would grow in order to keep net premium affordable. This wouldn’t help people with income over 400 percent of the poverty level, but 83 percent of Nevada exchange enrollees are receiving premium subsidies and would be protected from whatever rate increases were necessary to keep coverage available.
It’s also worth noting that lawmakers in Nevada passed a bill in early June that would have allowed people in Nevada to buy into the state’s Medicaid program (it’s unlikely that it would have been ready in time for 2018, even if it had been enacted). However, Governor Brian Sandoval vetoed that legislation, so it’s no longer on the table.
State’s approach to MCOs helps to bolster 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 is 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 are now down to three). And while they eliminated the requirement that Medicaid MCOs also offer QHPs in the exchange, the Nevada Division of Insurance reports 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 is entirely exiting the exchange at the end of 2017, does not have an MCO contract in Nevada).
But since then, Aetna has terminated their MCO contract and withdrawn their exchange plans, and Anthem has withdrawn their exchange plans. I reached out to the Nevada Department of Health and Human Services to better understand Anthem’s current position, which is 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’s some wiggle room in the MCO contracts at this point. 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 isn’t hampering 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 have done 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 offers plans in the exchange in 2017, and they are exiting Virginia’s exchange at the end of the year. So the only states where United will continue to offer exchange coverage in 2018 are states that have linked Medicaid managed care participation to participation in the exchange.
The MCO contract bidding process indicated an effort on Nevada’s part to keep insurers in the exchange, and is likely playing 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 has 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.
2017 enrollment: higher than 2017, and average full-price premiums well below national average
89,061 people enrolled in private plans for 2017 through the Nevada exchange during open enrollment. For perspective, enrollment during the 2016 open enrollment period reached 88,145. So enrollment grew by 1 percent in Nevada’s exchange — in contrast with the average across all states that use HealthCare.gov, where average enrollment was down about 5 percent in 2017.
UNLV was one of the universities around the country that took part in a last-minute push at the end of open enrollment to get “young invincibles” enrolled in coverage for 2017, and the exchange had a navigator on campus on Fridays through the end of January, to assist with the enrollment process.
Average full-price premiums in the Nevada exchange in 2017 are $379/month, which is considerably lower than the $476/month average across all HealthCare.gov states, and also lower than the $417/month average across the five state-based marketplaces that use HealthCare.gov (in 2017, that’s Nevada, Arkansas, New Mexico, Kentucky, and Oregon). But nearly 83 percent of Nevada exchange enrollees are receiving premium subsidies, and their after-subsidy premium is just $142/month.
The Nevada exchange and the Trump Administration: Governor Sandoval working to prevent 400,000 from losing coverage
In May 2017, House Republicans passed the American Health Care Act (AHCA) and sent it to the Senate. The bill passed by a narrow margin, 217-213 (it needed 216 to pass). The Senate crafted their own version of the bill, titled the Better Care Reconciliation Act (BCRA), in a completely partisan, closed-door process. Senate Republicans were not able to pass the BCRA, but have turned instead to the possibility of passing a “skinny” repeal bill (skinny because it has few provisions — it would still have a large impact). Their hope is that House Republicans would then work out a compromise with them during the conference committee process, but there is also a significant concern that the House could simply pass the “skinny” bill as-is, which would completely destabilize the individual health insurance markets (both on and off-exchange).
Governor Sandoval expressed his opposition to the BCRA, as has Nevada Senator Dean Heller, in large part due to the Medicaid cuts in the legislation and the fact that so many people would lose coverage (either directly, via Medicaid cuts, or indirectly, due to unaffordable premiums and/or sharply higher out-of-pocket costs and less-robust coverage). Heller voted against the BCRA as well as the Obamacare Repeal Reconciliation Act, and he called for the Senate to not reduce Medicaid benefits or eligibility for current enrollees (although he also wanted the Senate to prioritize Medicaid coverage for people with disabilities and significant medical need over the able-bodied).
As a result of the ACA, 294,000 people in Nevada gained health insurance coverage from 2010 to 2015. This includes all the avenues that the ACA created, including Medicaid expansion, which Nevada implemented. And by January 2017, Governor Sandoval reported that the total number of people who had gained coverage in the state as a result of the ACA had grown to more than 400,000.
At the National Governors Association State of the State Address, Nevada Governor Brian Sandoval discussed the possibility of repealing and replacing the ACA. Sandoval noted that “a lot of lives are at stake. I hope that decisions aren’t made in a vacuum and that there is a reach-out to the governors, because I can talk specifically about what we’re doing in our state.”
Sandoval noted that although GOP proposals to switch Medicaid to block grants (this is part of the AHCA and BCRA, along with an option to use per-capita allotments) would certainly give states more flexibility — which he supports — there would need to be safeguards in place to protect states from running out of Medicaid funds if an economic downturn results in more people being eligible for coverage. To be clear, the AHCA would cut $880 billion in federal Medicaid spending over the next decade; states would absolutely see less federal Medicaid funding under the AHCA. And the BCRA would cut Medicaid funding by $756 billion by 2026, but Medicaid cuts would be even more substantial under the BCRA in years after 2025; by 2036, the CBO projects that Medicaid spending would be 35 percent lower under the BCRA than it would be if the ACA remained unchanged.
295,000 still uninsured in Nevada, nearly half eligible for subsidies or Medicaid
There were still 295,000 uninsured residents in Nevada in 2016. Kaiser Family Foundation data indicates that 31 percent are eligible for Medicaid, and 14 percent are eligible for premium subsidies in the exchange. HHS estimates that there are also 27,000 people in Nevada who have coverage in the off-exchange market, but who would be eligible for premium subsidies if they switched to coverage in the exchange. Open enrollment is the chance to make that switch, and it ends on January 31, 2017.
In good news for Nevada, the state had the largest percentage point reduction in the number of uninsured children since 2013 – although Nevada had the highest rate of uninsured children in 2013 (19 percent as opposed to 10 percent nationwide).
2017 rates and carriers
The average benchmark plan (second-lowest-cost silver plan) in Nevada is 6 percent more expensive in 2017 than it was in 2016. Subsidies are tied to the benchmark premiums, so they are moderately higher in 2017 too. Nevada was one of only nine states on the HealthCare.gov platform with single-digit average benchmark premium increases for 2017. It’s important for enrollees to shop around during open enrollment though, as rate changes for some carriers are considerably higher than 6 percent.
The three carriers (four if you count Anthem’s PPO and HMO divisions as separate entities) that offered plans in the exchange in Nevada in 2016 are all continuing to participate in 2017. Their average rate increases for 2017 are as follows (membership count includes both on and off-exchange enrollment in 2016):
- Health Plan of Nevada (UnitedHealthcare’s HMO): 7.95 percent (down from the 10.4 percent increase that the carrier requested). Health Plan of Nevada had 50,564 members in 2016.
- Prominence (formerly Saint Mary’s HealthFirst): 17.08 percent (down slightly from the 17.51 percent increase that the carrier requested) Prominence had 10,977 members in 2016.
- Anthem BCBS (HMO Colorado/HMO Nevada): 8.76 percent (down significantly from the 14.24 percent increase that Anthem had requested in July, but roughly similar to the 8.58 percent increase that the carrier had originally requested). HMO Colorado/HMO Nevada had 9,667 members in 2016.
- Anthem BCBS (PPO, also called Rocky Mountain Hospital and Medical Service, Inc.) 14.04 percent (lower than the 18.93 percent increase that the carrier had requested in July, but a little higher than the 13.8 percent average rate increase they had initially filed; the highest average rate increase for RMHMSI was ultimately reduced from about 51 percent to about 25 percent. RMHMSI had 19,033 members in 2016. The carrier was new to the exchange in 2016, and the only PPO available through Nevada Health Link in 2016.
Anthem is the only insurer that offers exchange coverage in all 16 Nevada counties in 2017. Health Plan of Nevada is only available in three counties (Nye, Clark, and Esmerelda, all in southern Nevada). Prominence serves seven counties, including Nye and Clark. So in those two counties, there are plans available in 2017 from all three insurers.
At ACAsignups, Charles Gaba calculated the overall weighted average approved rate increase for the entire individual market in Nevada (including several carriers that only offer plans outside the exchange), at 10.57 percent for 2017, down from the 15.02 percent that the carriers had initially requested. The overall average increase in Nevada ended up significantly lower than the national average of about 25 percent.
For 2016, the average approved rate increase in Nevada was 9.58 percent, so 2017’s average rate increase is remarkably similar.
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) is available through the exchange, but they also have a PPO (Sierra Health and Life) that’s available off-exchange. According to a Kaiser Family Foundation analysis, UnitedHealthcare offers on-exchange plans in just three of Nevada’s 17 counties. But those three counties account for 90 percent of the state’s exchange enrollees.
For 2016 coverage, only Prominence continued to pay broker commissions on and off-exchange for enrollments outside of open enrollment (ie, during special enrollment periods). Anthem did not pay broker commissions outside of open enrollment at all, and UnitedHealthcare did not pay broker commissions for on-exchange enrollments outside of open enrollment.
Four carriers offer dental plans through Nevada’s exchange: Anthem, Alpha Dental, Best Life, and Delta Dental.
Year-round off-exchange enrollment
Nevada is the only state in the country where carriers selling plans outside of the exchange are required to make those policies available for purchase year-round. The carriers are allowed to impose a waiting period of up to 90 days before coverage become effective, a provision that was included in order to protect against adverse selection.
Residents in Nevada are still required to comply with the individual mandate or face a tax penalty, but they are also allowed to shop for new coverage outside of the exchange year-round, with plans that will go into effect after 90 days.
The availability of off-exchange plans year-round has caused some media confusion, and reports have been published indicating that residents can get policies through the exchange outside of open enrollment. This is not correct, however. The Nevada Health Link website clearly states on the homepage that enrollment is only available outside of open enrollment if you qualify for Medicaid or if you have a qualifying event.
Nevada Health Link is a state-run exchange, but is considered federally-supported because it uses Healthcare.gov’s enrollment platform.
Open enrollment for 2016 ended on January 31, and by February 1, enrollment in the Nevada exchange stood at 88,145. By March 31, effectuated enrollment had dropped to 79,876. Of those enrollees, 89.5 percent were receiving premium subsidies.
Enrollment in 2015 – at the end of open enrollment – stood at 73,596, so enrollment grew by almost 20 percent in 2016. And 2016 enrollment is more than double what it was in 2014, when it peaked at around 38,000 enrollees. Yet it’s still short of the initial – obviously optimistic – goal of 118,000 enrollees that Nevada Health Link had prior to the first open enrollment period in 2013.
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. 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.
Open enrollment for 2016 ended in January, but Nevada is the only state in the country where off-exchange enrollments are permitted year-round, with waiting periods (more details below). Native Americans and anyone eligible for Medicaid/CHIP can enroll year-round through the exchange.
The exchange had tightened up their accountability requirements for navigator organizations, after finding that invoices from navigator organizations in 2015 (in the months leading up to the open enrollment period for 2016 coverage) were often lacking in detail and didn’t include proof that the navigators attended the outreach events as stated.
Will Nevada Health Link use Healthcare.gov long-term?
Nevada Health Link switched to the Healthcare.gov enrollment platform in time for the second open enrollment period that began in the fall of 2014. In 2015, it was determined that this was a permanent change and Nevada was no longer looking for a private vendor to replace Xerox.
But whether or not that’s really the case still remains to be seen; Nevada Health Link’s executive director, Bruce Gilbert, noted in November 2015 that a future shift back to a state-run enrollment platform is still a possibility. He confirmed in April 2016 that Nevada would definitely use Healthcare.gov for enrollment in coverage for 2017, but exchange leadership met with CMS in July 2016 to “update the agency on [Nevada Health Link’s] efforts to identify and implement an integrated technology platform and call center for Plan Year 2018.”
Of course, all of this is very much up in the air until the future of the ACA (including HealthCare.gov) is determined. But for the time being, here’s what’s gone on in Nevada:
Healthcare.gov has been enrolling Nevada residents without charging the exchange a fee to do so, but the exchange will begin having to pay Healthcare.gov in 2017. HHS initially proposed a fee equaling 3 percent of premiums for states like Nevada that have a state-based exchange but use Healthcare.gov for enrollment (which would have amounted to $9 million in 2017 in Nevada, according to Gilbert).
In the final ruling that was issued in February 2016, HHS noted that the fee will be only 1.5 percent in 2017, but is expected to increase to 3 percent starting in 2018. This is in addition to fees the state-run exchange needs to implement in order to fund its own operation (HHS requires federally-supported state-based exchanges to run – at a minimum – an informational website that directs visitors to Healthcare.gov, and a phone hotline).
In February 2016 – before HHS announced that the fee would be 1.5 percent in 2017 – the Nevada Health Link board of directors unanimously approved a small increase in their total fee structure, in order to accommodate the possibility of a 3 percent Healthcare.gov fee in 2017. The exchange had been charging carriers a 3 percent fee, but noted that if Healthcare.gov took 3 percent, that would use up all of their revenue, with none left over for state-based exchange functions. As a result, the new fee will be 3.15 percent of premiums, which will cover the portion that must be sent to Healthcare.gov with a little left over (and will still be less than the 3.5 percent that’s collected in states that rely fully on the federally-run exchange).
The board noted that they were having to make the decision to set the fee without knowing for sure whether or not HHS would stick with the proposed 3 percent fee for 2017 (ultimately, HHS lowered it to 1.5 percent for 2017, to provide transitional relief for federally-supported exchanges).
But the final ruling on the Healthcare.gov fee didn’t come until the last day of February, and the exchange explained that their carrier partners needed time to develop rates for 2017, with a final – rather than proposed – fee structure in place. When the Nevada Division of Insurance put out their 2017 rate filing guidance for carriers, they incorporated the 3.15 percent fee.
Gilbert had indicated that at the 3 percent fee rate, Nevada Health Link might consider switching to already-successful enrollment platforms used by other state-based exchanges, and noted that the exchange was “not talking about building something from scratch.” Now that HHS has clarified that the fee will be lower than proposed in 2017, but will ultimately end up at 3 percent, the Nevada Health Link board will have to determine whether they want to stay with Healthcare.gov long term.
No ballot initiative to eliminate state-run exchange
Nevada’s exchange is still state-run, although it relies on Healthcare.gov’s technology platform for enrollments. But Sharron Angle, a Republican former member of the Nevada Assembly and current president of the National Association of Republican Assemblies (who was in the running for outgoing Senator Harry Reid’s seat, but lost in the primary), tried to change that. Angle set out to gather more than 55,000 signatures to get an initiative on the 2016 ballot that would call for the elimination of the state-run exchange, and a full switch to Healthcare.gov. The deadline was June 21 however, and by June 8, the petition drive was struggling to get the required number of signatures. Ultimately, it failed, as did Angle’s two other petition drives, due to a lack of signatures.
So far, no other states have abandoned a state-run exchange and switched entirely to Healthcare.gov (Nevada, Hawaii, Oregon, and New Mexico all still have state-based exchanges, despite using Healthcare.gov for enrollments; Kentucky has joined them as of the 2017 open enrollment period that started in November 2016.
The legislature only meets in odd-numbered years in Nevada, so there’s no regular session in 2016. Two pieces of anti-exchange legislation — AB368 and SJR14 — were considered by lawmakers in Nevada in 2015, but neither advanced to a vote. The Assembly bill would have repealed the provisions of Nevada law that permitted the creation of the state-run exchange. The Senate joint resolution would have implemented a constitutional amendment prohibiting the creation or operation of a state-run exchange.
CO-OP closed at the end of 2015
In late August 2015, the Nevada Health CO-OP 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.
Nevada Health CO-OP was created under the ACA’s CO-OP provision, and garnered 37 percent of the exchange’s market share in 2014 – far more than expected, and far more than most other CO-OPs. Their strong market share continued in 2015: In the first quarter of the year, the CO-OP’s membership was about 21,000 – about a third of the total private plan enrollees in the Nevada exchange at the time.
One issue that created problems for Nevada Health CO-OP was their generous enrollment protocol. Nevada is the only state in the country that allows off-exchange enrollment to run year-round, but carriers can implement a 90 day waiting period for benefits to begin, in order to discourage people from waiting until they need care to sign up. But the CO-OP let people enroll with no waiting period initially, and later added a 30 day waiting period in late 2014 The result was a membership that skewed towards sicker enrollees with higher claims costs.
By late May 2016, the Las Vegas Review Journal was reporting that Nevada Health CO-OP hadn’t paid any claims since “at least October” of 2015. Enrollees who paid their premiums through December were technically covered through the end of the year, but providers and vendors have not been paid for services rendered in the last quarter of 2015, leading some providers to send patients to collections. The receivership orders prevent them from doing this, but proper procedures haven’t been followed in all cases. If you’re a former Nevada Health CO-OP member receiving collections notices for outstanding bills that should have been paid by the carrier, you can contact the Nevada Division of Insurance for guidance.
2016 rates and carriers
There were five carriers that offered individual plans in the Nevada exchange in 2015, and there are three in 2016; but existing carriers have expanded their offerings.
The CO-OP closed at the end of 2015, and Assurant (Time) 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 those no longer apply, as their members had to select a plan from a different carrier for 2016.
But Anthem began offering PPO options in the exchange for 2016 (they only had HMO options in 2015). In addition, Prominence has expanding their plan offerings into Southern Nevada. Humana also joined the exchange for 2016, but only in the small-group market. For 2016, the individual market carrier options within the exchange – and their average approved rate increase for 2016, if applicable – are:
- Health Plan of Nevada (UnitedHealthcare): 8.3 percent increase
- Anthem BCBS (HMO): 11.4 percent increase
- Prominence (formerly Saint Mary’s HealthFirst): 2.94 percent increase
- Anthem BCBS (PPO) – new for 2016, and the only PPO available through Nevada Health Link in 2016.
At ACAsignups, Charles Gaba calculated the overall weighted average rate increase for the entire individual market in Nevada (including the carriers that only offer plans outside the exchange), at 9.58 percent for 2016.
But Anthem’s PPO option is new for 2016, and roughly a third of the exchange enrollees (who had coverage through the CO-OP or Time/Assurant) had to select coverage from a different carrier for 2016. For the remaining enrollees, the average premium increase within the exchange was 8.7 percent – but that’s assuming people didn’t shop around to find a better deal.
According to Healthcare.gov data, the average benchmark premium increased by 8.1 percent in 2016. But benchmark plans can change from one year to the next, so this number gives us more of an indication of how subsidies will change than any real data about how individual enrollees’ rates will change.
No walk-in Health Link enrollment stores
During the 2015 open enrollment period, although Healthcare.gov served as the enrollment platform, Nevada Health Link operated two brick-and-mortar walk-in enrollment centers – one in the Boulevard Mall in Las Vegas, and the other in Northern Nevada.
But it cost more than $50,000 per month to rent those locations, and less than ten percent of the 2015 enrollees received enrollment help at the walk-in centers. As a result, Nevada Health Link opted not to run the walk-in centers during the 2016 open enrollment period.
But in-person assistance is still available from brokers and navigators across the state, and the exchange held enrollment events throughout open enrollment. Nevada Health Link also operates a Consumer Assistance Center to provide phone support, which they opened on April 16, 2015 (Xerox was running a Nevada Health Link call center until April 15).
2015 enrollment – slow but steady growth
As of February 22 – at the end of the 2015 open enrollment period – 73,596 people in Nevada had enrolled in private plans for 2015. This was more than double the number of people who had enrolled by the end of the 2014 open enrollment period – when the exchange was using its own technologically-flawed enrollment platform.
But some enrollees didn’t pay their initial premiums, and some cancelled their coverage early in the year or their subsidies were eliminated due to lack of financial or immigration documentation. By the end of March, 62,944 had in-force private plan coverage through the Nevada exchange, and by the end of June, effectuated enrollment had dropped to 60,879 people; 81.7 percent of them were receiving premium subsidies – slightly lower than the national average of 83.7 percent (attrition is a normal part of the individual health insurance market, and a slow drop in net enrollment is to be expected during the three quarters of the year when enrollment is limited only to people who have qualifying events).
In addition to the private plan enrollments, there were 28,290 Nevada exchange enrollees who qualified for Medicaid during the second open enrollment period. Medicaid enrollment continues year-round, but tends to increase during general open enrollment due to the additional consumer outreach conducted by the exchanges, carriers, and HHS.
Since Nevada switched to Healthcare.gov for the 2015 enrollment period (after running their own exchange in 2014), everyone who enrolled in 2014 in Nevada needed to re-enroll in order to keep their subsidies for 2015. Thus the enrollment report showed that 100 percent of the 2015 enrollees were new to the exchange (as opposed to plans renewed from 2014).
Nevada’s exchange struggled significantly in 2014, and enrollment never reached even the modified goals the exchange had set. At its peak in the summer of 2014, total enrollment in private plans was about 38,000, and it had declined to under 33,000 by fall. So 2015’s numbers represented strong enrollment growth, even after accounting for attrition after open enrollment had ended.
Switching to HealthCare.gov
Things went much better for Nevada Health Link during the second open enrollment period, since they were using Healthcare.gov as their enrollment platform. On May 20, 2014, the exchange board unanimously voted to drop Xerox (the company that had been responsible for building the state-run exchange website) and switch to Healthcare.gov instead.
The state has retained some responsibilities – certifying private plans and determining Medicaid eligibility – and is still legally be classified as a state-run exchange. But HHS is handling enrollment; applicants are redirected to Healthcare.gov from the Nevada Health Link site. This type of set-up is known as a federally-supported state-based exchange.
Nevada Health Link 2015 renewals
Because Nevada switched to Healthcare.gov for enrollment, 2014 enrollees needed to re-enroll during the 2015 open enrollment period.
People who did not complete the re-enrollment process were automatically re-enrolled in their 2014 plan, but without premium subsidies. In order to continue to receive subsidies, people who enrolled through Nevada Health Link for 2014 needed to make sure that they re-enrolled for 2015.
In order to have had uninterrupted subsidies in January 2015, enrollees needed to complete their re-enrollment by December 15, 2014. If they missed that deadline, they were able to re-enroll anytime until February 15 (February 22 with the extension that was added), but in that case, they needed to pay their full premium up front in January. The Las Vegas Sun reported that 2014 enrollees who enrolled before the end of open enrollment would be able to recoup the subsidies that they didn’t receive in January (and February, if applicable).
In October 2014, Nevada Health Link began an aggressive outreach campaign to alert enrollees of the need to re-enroll, and they continued the outreach into December.
Oregon was the only other state to switch from running their own enrollment to utilizing Healthcare.gov for 2015, although Hawaii has joined them for 2016. In Oregon, 2014 exchange plans terminated on December 31, and enrollees had no choice but to re-enroll. In Nevada, a state law prohibits insurers from cancelling coverage, which is why the 2014 plans through Nevada Health Link didn’t terminate on December 31 if the insureds took no action to re-enroll, but were instead renewed – albeit without subsidies – into the new year.
2015 rates and carriers
Carriers in Nevada were required to file their 2015 rates by early September. Final approved rates were released by the Division of Insurance in mid-October. The average premium increase was 6.4 percent, although rate changes for 2015 range from a 6.9 percent decrease to a 24 percent increase.
But Las Vegas was one of the 16 metropolitan areas analyzed in a September Kaiser Family Foundation report that examined proposed rates for benchmark (second lowest cost) silver plans. According to the report, the benchmark silver plan – upon which subsidies are based – was proposed to rise by a very modest 1.7 percent for 2015.
Five health insurance carriers offered policies in Nevada’s exchange in 2015: Anthem, Assurant, Health Plan of Nevada, Nevada Health CO-OP and Prominence Health Plan (formerly Saint Mary’s Healthfirst).
Many improvements, including a new website
With Nevada Health Link relying on the now very-functional Healthcare.gov site for eligibility and enrollment, the state-run portion of the exchange is able to focus on consumer advocacy and assistance, without being bogged down by the technological problems that hampered the exchange during the 2014 open enrollment. The state launched their 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.
Nevada Health Link debuted a pre-screener tool for the 2015 open enrollment period; consumers answer six simple questions and are then routed to the appropriate section of the website.
The exchange also put a lot of emphasis on in-person assistance during the 2015 open enrollment period. They upgraded the portion of their site that helps consumers find local navigators, brokers and assisters. You can search by zip code and the results are displayed on a map so you can easily pinpoint the nearest in-person help.
Nevada Health Link also has a community events calendar on its website so that people can easily see when and where enrollment events are taking place.
2014 enrollment numbers
Nevada Health Link extended their 2014 open enrollment period to May 30 for people who experienced technical difficulties during the regular enrollment period. By the end of May, the exchange had enrolled about 35,700 people – short of their goal of 50,000 (which had been modified in early 2014, down from an original goal of 118,000).
Enrollment had climbed to about 38,000 by mid-summer, but had dropped to about 34,000 by early September, and to 32,460 by mid-October. Nevada Health Link’s attrition rate is thus higher than average (possibly the highest in the country – only 71.5% of the Nevada residents who were enrolled in April were still enrolled in mid-October), and the exchange has a lot of work to do to retain its customer base during the 2015 open enrollment period when they will all have to re-enroll.
In addition to the private plan enrollments, as of April 19, Nevada Health Link had also enrolled 182,946 applicants in the state’s Medicaid program, which was expanded under the ACA. Medicaid enrollment continues year-round, but tends to spike during open enrollment, due to outreach.
According to a Gallup poll, Nevada’s uninsured rate decreased from 20 percent in 2013 to 16 percent in mid-2014; it fell slightly to 15.2 percent by mid-2015. Nevada Health Link officials hope to reduce the state’s uninsured rate to 8 percent, so there is still a long way to go.
The lowest-cost bronze plan in Nevada’s exchange averaged $227/month in 2014, which is lower than the national average of $249.
Leading up to the 2015 open enrollment period, 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.
Applicants signing up during the 2015 general open enrollment – that started on November 15, 2014 – were directed to the federal call center for Healthcare.gov, while applicants enrolling in Medicaid (year-round) utilized a separate call center. There was some confusion in the transition, but officials decided this approach would be less expensive than completely revamping the existing state-run exchange.
In June 2014, the state announced that fixing the Medicaid portion of the exchange would cost $25 million, but the majority ($22.5 million) would be paid by the federal government.
Xerox and Nevada Health Link are settling their contract privately, without litigation. But in early April 2014, a class-action lawsuit was filed against Nevada Health Link, alleging gross negligence in the cases of residents who enrolled through the exchange, claim to have paid their premiums, and yet have applications that are still pending and no insurance coverage in force.
In mid-May, the exchange board indicated that they would “request that Xerox provide defense and indemnify the state of any consequences stemming from the class action lawsuit.” In addition to the consumers whose applications have not been correctly processed, Nevada Health Link was plagued with problems stemming from a failure to correctly assign and pay broker commissions.
Penalty exemptions for 2014 tech glitches
Because Nevada’s health insurance exchange was so technologically flawed in 2014, the IRS allowed an exemption for residents who were unable to complete the enrollment process. Bruce Gilbert, the executive director of the exchange, noted that “any Nevadan prevented from obtaining coverage due to a technology failure is eligible for an exemption from the individual-responsibility penalty.”
But in order to get that exemption, tax filers in Nevada needed to file form 8965 with the code “G” in the “exemption type” column when they filed their 2014 tax return. Requesting a “general hardship” exemption wouldn’t work, and Nevada residents started to get rejections from the IRS in June 2015 if they had filed that way. If you were unable to obtain coverage in 2014 because of the technological problems with Nevada Health Link and you need to file an amended return for 2014, you can resubmit form 8965 to the IRS with the correct exemption code.
In addition, many enrollees received incorrect data regarding 2014 coverage dates on their 1095-A forms that were mailed out in early 2015. To handle the problem and correct the errors, Xerox kept its Nevada Health Link call center open until April 15 – two weeks later than originally scheduled. Errors on 2014 1095-A forms was certainly not unique to Nevada – they happened in other state-run exchanges and also with Healthcare.gov.
During the August 2015 board meeting for Nevada Health Link, it was noted that they were still dealing with a small backlog of 1095-A errors, but they expected to have them all fixed by the end of August.
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’s exchange is overseen by a 10-member board, seven of which are voting members. Five of the voting members are appointed by the governor, and the other two are appointed by the state Senate majority leader. The three nonvoting members lead the state’s departments of Administration, Health & Human Services, and Insurance. In May 2015, AB86 was signed into law, allowing insurance agents and insurance carrier representatives to serve on the board of directors for the exchange.
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. Insurers can participate in both the individual and small-business exchanges.
In July 2014, Nevada Health Link selected Bruce Gilbert to be the new executive director, a position that has been open since mid-March when director Jon Hager resigned.
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)