Latest Nevada exchange updates
- Open enrollment for 2019 coverage in Nevada ended on December 15, but people losing Anthem grandfathered plans have extra time to enroll.
- Outside the exchange, enrollment continues year-round in Nevada (with a waiting period)
- Enrollment in the exchange is still open for Nevadans with qualifying events.
- Association health plans available to some chamber of commerce members in Nevada
- Short-term health plans are available in Nevada with initial plan terms up to 185 days.
- For 2019 plans, Nevada exchange premiums had a 0.4% average decrease.
- Nevada plans to switch back to fully state-run exchange by 2020.
- Enrollment in Nevada’s exchange hits an all-time high for 2018.
- Nevada’s approach to Medicaid managed care contracts helps to keep insurers in the exchange.
Overview of the Nevada exchangeNevada Health Link is a state-run exchange that uses HealthCare.gov for enrollment — although as described below, the state is working towards having their own enrollment platform in place by the fall of 2019.
There are five states in 2018 that have state-run exchanges but use HealthCare.gov for enrollment: Arkansas, Kentucky, Nevada, New Mexico, and Oregon. All five of those states had the same state-run exchanges using HealthCare.gov in 2017 as well.
Nevada is the only state in the country where plans purchased outside the exchange are available year-round. But there’s a three-month waiting period before coverage begins if you enroll outside of open enrollment and don’t have a qualifying event. The year-round availability is due to a Nevada state law. Premium subsidies and cost-sharing subsidies subsidies are not available outside the exchange, so anyone enrolling off-exchange pays full price for their coverage.
Enrollment continues until March 1 for people whose grandfathered Anthem plan is ending (enrollment also available year-round in Nevada outside the exchange, but with a waiting period)
Open enrollment for individual health insurance ended in Nevada’s exchange on December 15, with 83,647 people enrolled in plans through the exchange. But as noted above, Nevada is the only state in the country where coverage is available year-round outside the exchange, albeit with a 90-day waiting period.
And although on-exchange enrollment has ended for 2019 plans, people who have coverage under Anthem’s grandfathered plans have a special enrollment period to select a plan for 2019. They have until December 31 to enroll in a plan with a January 1 effective date (through the exchange or outside the exchange), and until March 1 to select a plan with a later effective date.
Anthem is ending all of their grandfathered plans in Nevada on December 31, 2018. Nevada did not permit grandmothered/transitional health plans to be renewed after 2013. And with the exception of off-exchange catastrophic plans, Anthem discontinued all of their ACA-compliant individual market plans at the end of 2017. So in 2018, Anthem’s only individual market plans were grandfathered plans (those purchased before March 23, 2010) and off-exchange catastrophic plans. They are continuing to offer off-exchange catastrophic plans in 2019, but no other individual market coverage (as described below, however, Anthem is partnering with the Las Vegas Chamber of Commerce to offer association health plans in Nevada).
Involuntary loss of minimum essential coverage is a qualifying event that triggers a special enrollment period, both on- and off-exchange. Grandfathered plans are not fully compliant with the ACA, but they still count as minimum essential coverage. So people whose grandfathered Anthem plans are terminating are eligible for a special enrollment period. The effective date rules are different: They can sign up as late as December 31 and still have coverage effective January 1. If they don’t, they’ll be uninsured as of January 1, but they’ll also have 60 days (through March 1) when they can enroll in a new plan, on- or off-exchange.
Average approved 2019 rates
Silver Summit joined the Nevada exchange for 2018, and is continuing to offer statewide coverage in 2019. They offered four plans in 2018, and that increased to six plans in 2019.
Health Plan of Nevada is continuing to offer plans only in Clark, Nye, and Washoe counties (where the majority of Nevada’s residents live). Their plan offerings have droppe from ten to nine.
The 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.
- Silver Summit: decrease of 1.1 percent (25,996 enrollees)
- Health Plan of Nevada (UnitedHealthcare): 0 percent (no rate change from 2018) (56,000 enrollees)
The final approved weighted average rate change for Nevada’s exchange is a decrease of 0.4 percent, indicating that the latest rate filings were approved largely as filed. That’s a far cry from the situation heading into 2018, when Nevada was grappling with the prospect of having 14 counties with no exchange insurers (that was averted with Silver Summit’s entry to the exchange), and Health Plan of Nevada raised their prices by almost 37 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 notes 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.
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 mid-September, 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. 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.
Exchange enrollment hit a record high for 2018, but dropped by about 8 percent for 2019
91,003 people enrolled in coverage through Nevada’s exchange during the open enrollment period for 2018 coverage. This was a 2.2 percent increase over the enrollment total in 2017, which had also been an increase from 2016.
While most exchanges saw increasing enrollment through 2016, the trend was towards a slight decrease in enrollment in 2017 and again in 2018. But despite the much shorter open enrollment period for 2018 coverage (just over six weeks, as opposed to the three-month window that had been used in previous years), enrollment continued to increase in Nevada.
The Nevada exchange ran an extensive marketing and outreach campaign leading up to the start of open enrollment for 2017 coverage, and once again ran an extensive outreach and marketing campaign before and during open enrollment for 2018 coverage. The exchange’s marketing and outreach budget was not impacted by the Trump Administration’s decision to cut federal funding for HealthCare.gov’s marketing and outreach (since Nevada has a state-run exchange, and only uses HealthCare.gov for enrollment).
For 2019 coverage, enrollment in Nevada’s exchange reached 83,647, 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 (association health plans are only a viable alternative to self-employed people who have access to an association).
Nevada is one of only a handful of states where exchange enrollment increased every year from 2014 to 2018, although as described above, enrollment decreased for 2019. In the first year, fewer than 36,000 people enrolled in Nevada’s exchange, and the exchange struggled with technology problems. In 2015, after switching to HealthCare.gov’s enrollment platform, Nevada’s exchange enrollment more than doubled, to above 73,000 enrollees. And in each of the three subsequent years, enrollment increased again. The exchange is planning to transition back to their own enrollmnet platform by the start of the seventh enrollment period, in the fall of 2019.
Nevada working towards a transition away from HealthCare.gov by the fall of 2019
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 has remained in place through 2018, but Nevada will once again be operating its own exchange by the fall of 2019.
As described above, the fact that Nevada has their own exchange gave the state the ability to avoid the funding cuts that the Trump Administration imposed on fully federally-run exchanges in 2017 and 2018, but it limited Nevada’s opportunities in some circumstances. For example, most of the fully state-run exchanges opted to extend open enrollment for 2018 coverage, but states that used HealthCare.gov (including state-run exchanges, like Nevada’s) had to comply with the December 15 enrollment deadline that HHS imposed.
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.
The federal government charges 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. But the government will increase that fee to 3 percent in 2019 (the fee in states that rely fully on the federally-run exchange is 3.5 percent). Nevada Health Link charges a fee of 3.15 percent, which will remain unchanged in 2019. The exchange uses the revenue from the fee to fund its own outreach and enrollment operations, and also to pay for the HealthCare.gov services — which currently takes well over half of the total amount generated by the state’s fee, and which will absorb nearly all of the state’s fee in 2019.
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 3 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 3 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 to implement a new and improved enrollment platform that creates a “better user experience” for consumers, insurers, and enrollment assisters, including brokers and navigators.
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 will 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 five-year, $24.5 million contract with GetInsured has to receive final approval from the Nevada Board of Examiners in August.
At their July 2018 board meeting, the Nevada exchange board outlined the anticipated timeline for the transition to a fully state-run exchange. The new system will be live as of September 1, 2019, and consumers will be able to browse 2020 plans as of the second week in October 2019. Open enrollment for 2020 coverage will begin November 1, 2019. And if all continued to go as planned, consumers enrolling in 2020 coverage in Nevada will be using Nevada Health Link, rather than HealthCare.gov.
In May 2018, the Nevada exchange also began working to fill two key positions — project manager and information security specialist — that will be integral for the transition to a fully state-based exchange. By the July 2018 board meeting, the chosen project manager had accepted the position, and the exchange had made an offer to an information security specialist.
Approved rates and plans for 2018
On October 2, 2017, the Nevada Division of Insurance announced that final rates for 2018 had been approved. They noted that seven insurance companies would offer plans in Nevada’s individual market in 2018 (with an average rate increase of 31.6 percent). But there are only two of those seven companies that are offering plans in the exchange for 2018: SilverSummit and Health Plan of Nevada (UnitedHealthcare). Silver Summit is the only available option in most rural areas.
- Silver Summit is new to the exchange for 2018, so there’s no applicable rate change from 2017. Silver Summit is offering four plans in the exchange statewide: One bronze plan, one gold plan, and two silver plans. Silver Summit is the only insurer offering coverage in 14 mostly rural counties in Nevada.
- Health Plan of Nevada: 36.8 percent average rate increase (plans are available only in Clark, Nye, and Washoe counties). Health Plan of Nevada proposed a 27.24 percent average rate increase for 2018, with a range of 19 percent to 36 percent, depending on the plan (there’s also a Health Plan of Nevada filing dated July 20 that has an average proposed rate increase of 28.9 percent). But the average approved rate increase for Health Plan of Nevada ended up at 36.8%. Health Plan of Nevada has 48,192 members in 2017.
There were several changes in plan availability for 2018:
- Anthem offered plans statewide in 2017, on and off-exchange. But all of their on-exchange plans terminated at the end of 2017, as they are only offering off-exchange plans in 2018.
- Prominence offered plans statewide in 2017, on and off-exchange, but is no longer offering any plans in the individual market, on or off-exchange.
- Aetna offered plans outside the exchange in 2017 (PPO plans via Aetna Life throughout the state, and HMO plans via Aetna Health in Clark and Nye counties), but those plans terminated at the end of 2017.
- Golden Rule offered plans throughout Nevada in 2017, outside the exchange, but they were not actively marketed, so membership was likely quite low. Those plans were discontinued at the end of 2017, and Golden Rule is no longer offering plans in Nevada.
- Sierra Health and Life offered plans outside the exchange in 2017, but they were not actively marketed. For 2018, they have reduced their coverage area to only Clark and Nye counties, so members in other areas of the state were not able to renew their coverage into 2018.
- Details for each insurer in various years are available on the Nevada Division of Insurance rate tool.
People who had on-exchange coverage that terminated at the end of 2017 were mapped to similar plans from another insurer if they didn’t return to the exchange by December 15 to pick a replacement plan. But they were still eligible for a special enrollment period, through March 1, 2018 during which they can pick a different option for the remainder of 2018.
People who had off-exchange coverage that terminated at the end of 2017 were uninsured as of January 1 if they hadn’t picked a new plan by December 31. But they still have access to the special enrollment period to pick a new plan for 2018, albeit with a short gap in coverage. The ACA’s individual mandate is still in place in 2018 (the GOP tax bill doesn’t repeal it until 2019), but there’s an exemption for a single gap in coverage that lasts only one or two months. So as long as the new plan takes effect by March 1, enrollees in this situation won’t face a penalty, assuming they keep their new coverage in place throughout the rest of the year.
Average rate increases are calculated across all members, and actual rates vary considerably from one plan to another. You can use this site to see actual approved rates in Nevada for specific counties and enrollee ages.
Although Silver Summit is new to Nevada’s individual market and thus does not have any applicable rate increases, Silver Summit is offering the only available exchange plans to people in 14 Nevada counties (all but Clark, Nye, and Washoe). You can use the Nevada Division of Insurance rate page to see how 2018 Silver Summit rates and plans in those counties compare with the options that were available in 2017.
As an example, a 40-year-old in Esmerelda county could choose from 19 exchange plans that ranged in price (before subsidies) from $426/month to $756/month. In 2018, a 40-year-old in Esmerelda will have four plan options that range in price from $544/month to $789/month.
Keep in mind that the prices do not include the impact of premium subsidies. In Nevada, 85 percent of exchange enrollees were receiving premium subsidies as of February 2107, and the subsidies averaged $287/month. Premium subsidies continue to be available in 2018, and are substantially larger than they were in 2017, due to sharply higher rates for silver plans (premium subsidies are based on keeping the after-subsidy cost of the second-lowest-cost silver plan at a level that’s considered affordable).
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).
Nevada applied CSR load to on-exchange silver plans
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 healthcare market,” and the exchange reiterated that point in September, explaining that instability caused by the federal government is driving rates in the individual market far higher than they would otherwise be for 2018.
But it’s noteworthy that the July rate filing for Health Plan of Nevada (28.9 percent average rate increase) was based on the assumption that cost-sharing reduction (CSR) funding would continue in 2018. However, funding had not been allocated by Congress as of the September deadline to finalize rates, and the Trump Administration ultimately eliminated CSR funding altogether in October 2017, after repeatedly threatening to do so.
The Division of Insurance’s press release about the approved rates didn’t address the CSR funding issue, but they confirmed by email that the final rates were based on the assumption that federal funding for CSR would not continue in 2018 (given the Trump Administration’s subsequent announcement that CSR funding would end, this was a good call on the part of Nevada insurance regulators). The additional cost to cover CSR has been added to on-exchange silver plans (if those same plans are offered off-exchange, the price has to be the same). But there are also some silver plans that are only available off-exchange, which means that the additional premiums to cover CSRs has not been added to those plans.
This strategy is the one that provides the most protection to the most people: The higher premiums to cover the cost of CSR are added to on-exchange silver plans, and most people who buy them will receive premium subsidies that will offset the higher premiums. In addition, premium subsidies for people who buy bronze or gold plans will be larger than they would otherwise be, which makes the after-subsidy cost of bronze and gold plans lower than it would otherwise be.
And for people who want silver plans but don’t receive a premium subsidy, there are off-exchange-only silver plans available without the additional premium to cover CSRs, and there are also “extended bronze” plans available (actuarial value of roughly 65 percent) that don’t have the CSR load included in their premiums. The “extended bronze” plans use the new de minimus range (-4/+5) that applies to bronze plan actuarial value starting in 2018 (this extended actuarial value range was part of the market stabilization rule that HHS finalized in April 2017).
These extended bronze plans have actuarial values around 65 percent. This is roughly in the middle between previous years’ silver and bronze plans, which have typically had actuarial values of roughly 70 and 60 percent, respectively. Health Plan of Nevada will offer them on and off-exchange in Clark, Nye, and Washoe counties. Silver Summit, the only on-exchange insurer in the rest of the state, will not offer any off-exchange-only plans, but there are other insurers that will offer off-exchange-only plans, with a variety of silver and extended bronze plans available.
The Nevada Division of Insurance has a web page where consumers can see actual rates based on county and age for each carrier — including proposed and approved rates. For silver plans sold in the exchange, Health Plan of Nevada’s approved rates were considerably higher than the proposed rates, due to the CSR load that was added after the rates were initially filed. But for bronze, gold, and catastrophic plans, and for all of the insurer’s off-exchange plans, the approved rates were fairly close to the proposed rates.
Silver Summit only offers Medicaid/CHIP (Check Up) plans in Nevada in 2017, but they joined the exchange for 2018. Silver Summit is a subsidiary of Centene, and the insurer announced in June that in addition to Nevada, they would also join the exchanges in Missouri and Kansas for 2018, and expand their existing coverage area in several other states.
Since 2018 will be Silver Summit’s first year in the individual market in Nevada, they have no applicable rate increase. But similar to Health Plan of Nevada, Silver Summit’s biggest difference between proposed and approved rates is for silver plans. Their bronze and gold plans have approved rates that are much closer to proposed rates, but the approved rates for silver plans are considerably higher than proposed, because the CSR load has been added to the silver plans. All of Silver Summit’s plans are available on the exchange, which means that all of their silver plans include the CSR load.
With Silver Summit’s expanded coverage area, all counties have coverage in 2018
90 percent of the exchange enrollees in Nevada were 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 all continued offering coverage for 2017. This included UnitedHealthcare, which only remained in three exchanges for 2017 — Nevada was 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 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 were “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) agreed to offer coverage in all 14 counties. As a result, all Nevada residents have at least one insurer offering plans in the exchange for 2018.
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 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 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 (notably, Centene has been the insurer that filled quite a few of the bare counties, just as they’re doing in Nevada).
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 was the only insurer that offered 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 do not have an exchange presence anywhere in the country in 2018.
Prominence, which offered coverage in seven Nevada counties in 2017, announced in June that they would 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 was the only Nevada insurer that offered 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 continued to offer a catastrophic plan statewide outside the exchange, but did not have any exchange options available for 2018. [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 actually 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 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’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.
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), but for the time being, they do have exchange coverage available in all areas of the state for 2018.
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.
2017 rates and carriers
The average benchmark plan (second-lowest-cost silver plan) in Nevada was 6 percent more expensive in 2017 than it was in 2016. Nevada was one of only nine states on the HealthCare.gov platform with single-digit average benchmark premium increases for 2017.
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 all continued 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 2016, 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 was the only insurer that offered exchange coverage in all 16 Nevada counties in 2017. Health Plan of Nevada was only available in three counties (Nye, Clark, and Esmerelda, all in southern Nevada; this continues to be Nevada Health Plan’s coverage area in 2018). Prominence served seven counties, including Nye and Clark. So in those two counties, there were plans available in 2017 from all three insurers.
At ACA Signups, 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 was 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 offered dental plans through Nevada’s exchange in 2017: 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.
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. That dropped to three in 2016, but existing carriers 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 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. For 2016, the individual market carrier options within the exchange – and their average approved rate increase for 2016, if applicable – were:
- 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 was 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.
A switch to HealthCare.gov for 2015
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.
Early technological challenges
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.
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)