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; 87 percent are receiving premium subsidies. The 2016 enrollment total already accounted for some early attrition; enrollments that were cancelled for any reason by February 1 (including initial premiums not paid by the due date) had already been subtracted from the total.
Enrollment in 2015 – at the end of open enrollment – stood at 73,596, so enrollment grew by almost 20 percent, despite the fact that some early attrition is baked into the 2016 total (in 2014 and 2015, HHS waited until later in the year to begin reporting effectuated enrollment numbers and subtracting cancelled/unpaid enrollments from the total).
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 is over, 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.
Will Nevada Health Link stay with Healthcare.gov?
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.
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.
A 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 recently announced that she’ll run for outgoing Senator Harry Reid’s seat), wants to change that. Angle is working 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.
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 is expected to join them in 2017).
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.
Reaching the uninsured
According to a Kaiser Family Foundation analysis, there were still 350,000 uninsured residents in Nevada in 2015. 42 percent of them were eligible for Medicaid, and 17 percent were eligible for premium subsidies in the exchange (census data put the total number of uninsured residents at more than 431,000 in 2014). Nevada Health Link targeted their outreach efforts to focus on uninsured residents during the third open enrollment period, and they had licensed agents with extended office hours three days a week during open enrollment.
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).
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.
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 has begun 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 has 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, 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.
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 in advance 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.
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)