State Marketplace Profiles: Nevada

Final update made on September 26, 2013 (no further updates will be made )

Establishing the Marketplace

On June 16, 2011, Nevada’s Governor Brian Sandoval (R) signed SB 440 into law establishing the Silver State Health Insurance Exchange.¹ In March 2013, the state announced that the online marketplace would be called Nevada Health Link.

Structure: The legislation defines Nevada’s Exchange as a quasi-governmental organization.

Governance: The Marketplace is governed by a 10-member board, including three ex officio, non-voting members (or their designees): the Director of the Department of Health and Human Services, the Director of the Department of Business and Industry, and the Director of the Department of Administration. The Governor appoints five of the voting members, while the Senate Majority Leader and the Speaker of the Assembly each appoint one voting member. The legislation specifies that voting members should possess subject expertise in areas such as: individual or small employer health insurance markets; health care administration, financing, or information technology; health care delivery system administration; or experience of consumers that would benefit from the Exchange. Voting members cannot be Legislators or hold an elected office in Nevada state government, nor can they be affiliated with, have ownership interest in, or be a representative of a health insurer.

On September 23, 2011, the final board members were appointed.² The voting members are:

• Lynn Etkins, Legal Aid Center of Southern Nevada
• Dr. Judith Ford, Canyon Gate Medical Group
• Leslie Ann Johnstone, Health Services Coalition
• Marie Martin Kerr, Kerr Intellectual Property Law Group
• Dr. Ronald Kline, Comprehensive Cancer Centers of Nevada
• Elsie Lavonne Lewis, Clark County Urban League
• Barbara Smith Campbell, Consensus

The Marketplace Board hired an Executive Director in December 2011. The Board is required to submit fiscal and operational reports to the Governor and legislature by June 30 and December 31 of each year.

The Board established five advisory committees to provide recommendations on Marketplace implementation in the following areas: finance and sustainability; plan certification and management; Small Business Health Options Program (SHOP) Exchange; reinsurance and risk adjustment programs; and consumer assistance. The Advisory Committees met regularly starting in March 2012, and the Board approved 35 of their recommendations. As of May 2013, the Advisory Committees were disbanded and will no longer meet.³

The Marketplace Board completed a Tribal Interaction and Impact Assessment and is using the information to reach out to the state’s Tribes. The Marketplace has also signed a Tribal consultation agreement with the Indian Health Board of Nevada.⁴

Contracting with Plans: In April 2012, the Nevada Health Link Board approved guiding principles recommended by the Plan Certification and Management Advisory Committee, which included adopting a “Free Market Facilitator” model that “ensures the maximum participation by insurers and the widest choice for consumers.”⁵ In September 2012, the Board approved allowing carriers to offer Qualified Health Plans (QHPs) in either or both the Individual and SHOP Marketplaces at their discretion and that QHPs not be required to be identical in each Marketplace.⁶ Carriers are required to offer one silver level plan and one gold level plan, and silver level plans must offer cost-sharing variations of 73%, 87%, and 94% actuarial value. Carriers must also offer a zero cost-sharing version of all plans for American Indians as well as child-only plans at the same level of coverage as any other plan offered through the Marketplace. Catastrophic plans may only be offered in the individual market and to individuals under the age of 30 or to individuals with a certification for hardship exemption in effect.⁷ Also, each licensed carrier may not offer more than five QHPs in each metal tier (including a catastrophic tier) in each Marketplace.

In April 2013, the Board approved network adequacy standards that require carriers to ensure sufficient numbers and types of providers to meet the needs of the enrolled population, to comply with the Affordable Care Act’s Essential Community Provider requirement, and to include at least one community hospital in the provider network, if available. The Board established network adequacy ratios and travel standards according to county and provider specialty. Carriers may employ telemedicine to meet these accessibility requirements.⁸ Carriers must make their provider directories available to the Exchange for publication online and to enrollees in hard copy, if requested.

Four carriers will offer plans on Nevada Health Link in 2014. Individual market QHPs will be in place for one year and changes to plans may only be made prior to the open enrollment period. In September 2013, the DOI approved rates for plans that will be available in the individual and SHOP Marketplaces.

Risk Adjustment, Reinsurance, and Risk Corridors: The Board approved plans to conduct an analysis to determine whether Nevada-specific factors should be used in a risk adjustment model and continues to discuss whether the state should administer the reinsurance program or defer to the federal government.⁹

Dental and Vision Benefits: In March 2013, the Board decided that all QHPs that provide the pediatric dental essential health benefit must submit the dental benefit as a rider for the product. In April, however, the Centers for Medicare and Medicaid Services (CMS) determined it would not recognize riders for the pediatric dental essential health benefit. The Plan Certification and Management Advisory Committee met twice in May and ultimately recommended that the Marketplace allow the pediatric dental benefit to be embedded in a QHP, bundled with a QHP, or sold as a stand-alone plan.¹⁰ All children enrolled in a QHP through Nevada Health Link must purchase the pediatric EHB. Annual out-of-pocket maximums will be limited to $700 for one child and $1,400 for two or more children enrolled in stand-alone plans.¹¹

Consumer Assistance and Outreach: In December 2012, the Board approved a Navigators, Enrollment Assisters, Certified Application Counselors (CACs), and Producers Plan, detailing how the four entities will work together to enroll eligible individuals through Nevada Health Link. The primary function of Navigators will be to provide enrollment assistance and educational outreach, while Assisters will focus solely on application and enrollment assistance. Certified Application Counselors (CACs) will provide enrollment assistance and will largely work in hospitals.¹² CACs will not be compensated by the Marketplace. In June 2013, Nevada Health Link announced the eight organizations that have been selected as Navigator/Enrollment Assister grantees.¹³ Navigators, Enrollment Assisters, and CACs must receive Exchange Enrollment Facilitator (EEF) Certification from the DOI prior to enrolling individuals or employers in a QHP. Certification requirements include taking a 20 hour training course, passing a test with a score of 70% or better, and undergoing a background check.¹⁴ The first assisters were certified the first week of September. After becoming certified, Navigators, Enrollment Assisters, and CACs must complete a four-hour training course run by the Marketplace.

Over 1,200 agents and brokers intend to sell coverage through Nevada Health Link.¹⁵ In order to sell insurance products through the Marketplace, producers must register with the Marketplace, fulfill training and testing requirements, and satisfy the Marketplace’s privacy and security standards. Most training will be completed during the last week of September, although training courses will be available year-round. Producers will not be compensated by Nevada Health Link but will continue to receive compensation from carriers, in the same or similar manner as is done today in Nevada. The Board approved a recommendation that web-brokers will not be able to sell QHPs and access Advanced Premium Tax Credit and Cost Sharing reductions through their portals.

The state released an RFP in September 2012 for help planning a marketing and branding campaign in English and Spanish for the Marketplace, and in January 2013 entered into a contract with a vendor.¹⁶ The campaign is broken out into three phases: Marketplace branding, education, and call to action. In March 2013, the Board approved Nevada Health Link as the new Marketplace name and in April approved the logo, color palettes, and taglines.¹⁷ In June 2013, Nevada Health Link launched a website for consumers, including a subsidy calculator.

The marketing campaign launched July 1 and uses a mix of mediums to reach target audiences, including television, radio, print, and digital media. Nevada Health Link awareness advertising will run from July 2013 through March 2014, with three distinct waves of messaging. Television advertising launched on September 15 and will run through mid-October. Messaging for the “call to action” phase of the campaign is being developed and will be launched mid-October.¹⁵ Nevada Health Link will also partner with non-profit, state-based, and school-based organizations throughout the state to perform outreach activities through September 30.¹⁸ Hispanics, families with children, and male young adults with incomes between 138-400% FPL are the target populations for the marketing and outreach campaign.¹⁹

On September 16, the state opened the consumer call center.  In September 2013, Nevada Health Link announced that the launch of the Spanish-language portal will be delayed until mid-November. However, consumers will have access to Spanish-speaking call center representatives, in-person assisters, and producers.¹⁵

Small Business Health Options Program (SHOP) Marketplace: In April 2012, the Nevada Health Link Board approved guiding principles recommended by the SHOP Advisory Committee. In September 2012, the Board approved keeping the Individual and SHOP markets separate, as well as keeping the market for small groups (1-50) and mid-sized groups (51-100) separate until they have to be merged in 2016. The Marketplaces’s certification requirements for QHPS in the Individual and SHOP Marketplaces will be the same.

The SHOP Marketplace will offer three options to employers. The ‘Open SHOP’ option allows an employee to access all SHOP QHPs. The ‘Open Metal Tier’ option will allow an employer to select a specific metal tier for his/her employees. The ‘Package Option’ will let an employer select a specific package for his/her employees. Employers must contribute at least 50% of premiums for the lowest cost QHP available to employees.  The minimum employee participation rate is 75%.¹⁷

Financing: In June 2012, the Board approved exempting insurers from being taxed on fees charged by the Exchange.²⁰ The Board also rejected a proposal by the Committee to use a General Fund appropriation as a supplementary source of Exchange revenue by subsidizing individuals’ enrollment fees.²¹ In January 2013, the Board adopted a regulation establishing a monthly fee charged to insurers for each member enrolled in the insurer’s plans.²²  The Marketplace established separate fees for QHPs that do not include a dental component, QHPs that include dental, and stand-alone dental plans.²³

Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through Nevada Health Link, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. On December 14, 2012, the Insurance Commissioner announced the selection of Health Plan of Nevada POS C-XV-500-HCR as the EHB benchmark plan, the Children’s Health Insurance Plan (CHIP) as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement.²⁴

Marketplace Funding

In September 2010, the Nevada State Department of Health and Human Services received a federal Exchange Planning grant of $1 million. The Department has since received four federal Level One Establishment grants: $4 million in August 2011, $15.3 million in February 2012, $4.4 million in May 2012, and $9 million in July 2013. The grants will be used to develop a rules-based eligibility engine that will serve as the single, streamlined eligibility process for all medical assistance programs in the state, to support information technology security requirements, and to fund training for EEFs. In August 2012, the state received a federal Level Two Establishment grant for $50 million; this will fund Exchange operations through December 2014.²⁵

Next Steps

On January 3, 2013, Nevada received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.²⁶ The Nevada Health Link Marketplace portal will become operational on October 1 and will begin enrolling qualified individuals, families, and small businesses into coverage.

Additional information about the Silver State Health Insurance Marketplace can be found at:
http://exchange.nv.gov/