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Nevada’s Insurance Exchange Director Talks about Transitioning to a State-Based Marketplace and Saving Millions
NV Exchange Director Heather Korbulic
Nevada’s marketplace is poised to become the first to transition from the federal platform to an entirely state-run exchange. Its director explains how the move will save millions and improve residents’ health insurance.
Under the Affordable Care Act, states can either administer their own health insurance marketplaces as state-based marketplaces (SBMs), or default to the federally-run marketplace. Nevada is one of five states that operate a hybrid model – a state-based marketplace that uses the federal platform. These hybrid states are responsible for plan management and outreach and recruitment, which includes marketing activities, running local call centers, and coordinating with the state insurance department, while using the federal government’s technology platform and website to perform eligibility and enrollment functions.
Nevada’s marketplace – Nevada Health Link — is poised to become the first state in the nation to move away from the federal marketplace and transition to a full SBM. By transitioning, Nevada seeks greater flexibility to operate a marketplace tailored for its residents, while enabling the state to save millions in operational costs.
NASHP sat down with Nevada Health Link Executive Director Heather Korbulic to discuss the motivation behind Nevada’s transition, the value of state autonomy, and the future of the marketplaces.
Can you share the history of Nevada Health Link and why you are making this change?
To provide some history, in 2011, Nevada had approved statute to operate an SBM. However, when that SBM launched in 2014, the system did not work, creating significant issues for our consumers and carriers. Nevada had to decide whether to try again or begin using the federal platform—mostly to conduct required eligibility and enrollment functions. The FFM [federally facilitated marketplace] was essentially working at that time, and our board decided to transition to the SBM-FP model [state-based model that used the federal platform].
For the first two years as an SBM-FP, Nevada did not pay to use the federal platform, but in 2015, we were given notice that SBM-FPs would be required to pay a user fee. In 2017, the fee was set at 1.5 percent of premiums of plans sold through the marketplace, going up to 2 percent in 2018, and 3 percent thereafter. For comparison, the FFM collects a 3.5 percent assessment from insurers who offer coverage in FFM states.
In total, Nevada charges insurers in our state an assessment rate of 3.15 percent of premiums to [sell plans and] operate the marketplace. With the planned increases to the user fee, in 2019, Nevada would be left with only 0.15 percent of the assessment to conduct all of the functionality required of the SBM-FPs. We believe this would make the marketplace insolvent and unable to adequately perform its required functions.
Could you help us understand what these functions are—what distinguishes you from the FFM?
SBM-FPs operate local consumer assistance centers and conduct plan certification. We do stakeholder engagement in coordination with sister agencies like Medicaid and the state health department. As a state agency, we comply with all state oversight requirements along with federally-required oversight requirements for the marketplace. We operate the state navigator program, and do all our own marketing and outreach. A significant portion of our budget goes to outreach, as we have seen this as key to generating robust enrollment [which helps drive competition and affordability]. The federal government is responsible for the Healthcare.gov website and operating the integrated eligibility system for the state. (See Table 1 for a comparison of marketplace models.)
I think the role of the SBM-FPs is overlooked in discussions of the marketplace. The Nevada exchange has really honed in on our capabilities as a resource for Nevadans. We have become an important part of our community and have demonstrated success. Our consumers, carriers, state agencies and lawmakers have come to depend on us to answer their questions. Nevada lawmakers and our governor have shown commitment to the value that our marketplace has brought to our state.
This past year has given us some of the best insight into the value of having some state authority over our functionality. The national cuts to marketing and outreach this open enrollment period, and the confusion surrounding the existence of financial subsidies led to enrollment declines in many FFM states. By contrast, Nevada saw an increase in enrollment this year of 2.2 percent. We believe it had everything to do with our marketplace being a resource for Nevadans to connect to subsidies, and our work with our navigators and stakeholders to hammer the message of this year’s shortened enrollment period through focused marketing.
| Table 1. State or Federal Authority over Marketplace Functions in Different Marketplace Models | |||
| Marketplace Functions | State-Based Marketplaces (SBM) | State-Based Marketplaces Using the Federal Platform (SBM-FP) |
Federally Facilitated Marketplaces (FFM) |
| Plan Management | |||
| Set and collect plan assessments | State | Both* | Federal |
| Qualified health plan review and certification | State | State | Federal** |
| Outreach and Marketing | |||
| Navigator/Assister program | State | State | Federal |
| Marketing and advertising | State | State | Federal |
| Agent/broker program | State | State | Federal |
| IT/Operations | |||
| Integrated eligibility system | State | Federal | Federal |
| Enrollment website | State | Federal | Federal |
| Online consumer tools (e.g., calculators, provider directories, formularies) | State | Federal** | Federal |
| Call center | State | Federal** | Federal |
| Set special enrollment periods | Both*** | Federal | Federal |
*Plan assessments are fees paid by insurers to sell their insurance product through a marketplace. In SBM-FP states, the FFM collects a portion of assessments, known as a user fee, to operate the FFM. The SBM-FP user fee was 1.5% of premiums in 2017, 2% in 2018, and will be 3% in 2019.
** While the federal government has primary responsibility for these functions, many states also perform these functions to assure compliance with state standard or to ensure consumers have access to resources tailored to state-specific needs.
*** The parameters for special enrollment periods (SEPs) are defined by federal statute and regulation, but SBMs have flexibility to institute SEPs responsive to exceptional circumstances identified by the SBM.
What sort of improvements and savings do you anticipate after moving to the SBM model?
Nevada is in a good position to negotiate, we are essentially asking vendors for a “marketplace in a box” with all the pieces we need to make this work. We are a state agency with finite resources and want to clearly understand the costs of this packaged system — including technology and call center operations — so we can assess if it is affordable and whether it will be at a lesser cost than the FFM. Many vendors have now developed tested and proven products in this regard, with a limited market to sell them to—it is a win-win for them to work with us. Together, we will find savings and efficiencies to offer a better user experience and help our consumers.
From our initial research, we have found that Nevada could save significantly by moving to a fully functional, demonstrated product. In 2020, the 3 percent user fee will be approximately $12 million for our state, but we estimate that with our own platform operational costs will be closer to $6 million — a savings of 50 percent!
We also believe this is a chance for us to control our own destiny by managing our own marketplace. Having been an SBM-FP for several years now, we have seen the limitations that come with working with the FFM. There is very little flexibility given to states — any small change we request to try to tailor the system is almost impossible to accomplish.
There is also a lack of insight into our own state’s data. Without data, we have no sense of who our consumers are at any given moment. We are periodically provided zip code-level data breakdowns from CMS [Centers for Medicare & Medicaid Services] during the year but, for the most part, we do not know who is actively engaged in the system during the open enrollment season or other detailed information necessary to conduct truly targeted outreach. We think there are budgetary efficiencies to be found by having access to our own data — it will enable us to potentially increase enrollment and gain efficiencies from more direct consumer targeting.
What have you learned from other SBMs that helped guide Nevada’s approach?
I have learned a tremendous amount from my colleagues across the country as far as the technical components of how an SBM operates, however, what I have really walked away with is that no two SBMs are alike. There are so many differences in the ways that SBMs operate depending on how the marketplace fits in the state. This has been a helpful observation for Nevada because we know how we operate now, and we want to bring on a system that can accommodate what we want to do and will work with our state’s insurers and agencies like Medicaid.
| “What I have really walked away with is that no two SBMs are alike. There are so many differences in the ways that SBMs operate depending on how the marketplace fits in the state.” |
What advice do you have for states that are exploring a transition to an SBM?
Potentially, a state would need to pass some enabling legislation. Then they would need to invest in state agency staff and a small budget to operate the marketplace before it can begin collecting revenue. In Nevada, we have set aside $1 million for design, development, and implementation of our marketplace. Ultimately, it is a matter of investing and committing to the values that a SBM brings to a state and finding long-term savings.
There are many pending federal policy changes that bear national significant implications for health insurance coverage and marketplaces. What could these changes mean for consumers in Nevada?
In 2017, and continuing into 2018, we have seen uncertainty related to the ACA. We have come through the legislative endeavors to repeal the ACA last year, and now we are looking at executive rulemaking processes that could create disruption for our markets in Nevada.
I am concerned about rule-making related to Association Health Plans and what ability the state has to regulate those plans. I am also concerned about the Short Term Limited Duration Insurance proposed regulation. There is a time and place for short-term plans — for when consumers are between jobs or if they missed the open enrollment period — but these plans are not long-term solutions. We are concerned that consumers who do not qualify for premium subsidies will see these short-term plans as viable alternatives to qualified health plans, even though they do not offer the same level of benefits or consumer protections. We have seen some brokers try to game the system by directing consumers to enroll in a string of short-term plans, so that they can gain commissions for each enrollment, but ultimately that is not in the best interest of the consumer [who will have limited coverage, and have to manage constant shifts in benefits and networks].
During this upcoming open enrollment period, our marketplace will be focused on education campaigns to make sure we demonstrate to our consumers the value of having continuous coverage that meets the standards required for qualified health plans.
Is there anything else you feel it is important for leaders and consumers to know about your transition?
Everything that Nevada has had control over has been a demonstrable success. We have successfully made ourselves known as a resource in our community and for our consumers; we really are an important institution in our state. I believe the investments we are making in our new platform and the resulting savings we will achieve should be of interest to every state that wants to bring value to their insurance landscape.
View Nevada’s Request for Proposal for a technology vendor to help the state become a fully state-operated program.
Thank you to Heather Korbulic and Janel Davis of Nevada Health Link for their time and contributions to this article. Thank you to Christina Cousart, Trish Riley, Chris Kukka, and Rohan Narayanan for their critical support and feedback to this blog.
NASHP supports the State Health Exchange Leadership Network that provides a platform for state health insurance marketplaces staff and leaders to participate in peer-to-peer dialogue, discuss emerging issues, and share best practices. To learn more about the Network or NASHP’s work with the state-based marketplaces, contact Christina Cousart (ccousart@oldsite.nashp.org)
Legal Challenges of Rx Drug Laws Passed in 2017 Will Shape States’ Future Cost Containment Legislation
As the number of state bills to rein in prescription drug prices grows beyond 150 nationwide in 2018, the first generation of several state laws passed last year are now before the courts. The pharmaceutical industry has consistently challenged drug cost transparency and price gouging legislation passed in 2017 in federal courts. How well these state laws weather their legal challenges will determine how states shape their drug cost containment legislation in 2018 and beyond. Read more.
Searching for New Insurance Options, States Consider Medicaid Buy-In and Other Strategies
Shutterstock.com
Uncertainty about the future of health insurance options and concern about the ability of Affordable Care Act (ACA) marketplaces to offer adequate competition and choice have spurred states to look for new coverage approaches. Among the innovative strategies states are proposing are allowing consumers to buy into state Medicaid programs and developing state-specific coverage options within the ACA’s framework.
State Medicaid Buy-In Proposals
A new strategy some states are examining is to allow individuals who are not currently eligible for Medicaid to buy into the program. Cindy Mann of Manatt Health recently explored this proposal at a session at NASHP’s annual health care policy conference. She outlined some of the key issues that states need to consider to implement this approach.
One approach allows states to offer Medicaid as a new “public option” product in their ACA marketplaces, which could help increase affordability and consumer choice, particularly in areas where there are a limited number of participating plans. To be offered on the marketplace, a Medicaid plan would need to match marketplace coverage standards and be certified as a qualified health plan. Some session attendees wondered if a state could “deem” a Medicaid plan as qualified, particularly in bare counties where no insurance product was available.
Another way states could leverage Medicaid to expand coverage would be to permit individuals with incomes above current Medicaid eligibility levels to buy into the program. States could choose to offer this Medicaid buy-in to consumers either with or without subsidies. However, if they offered subsidies, states would need to seek federal approval through a 1332 Waiver or obtain a Basic Health Program (BHP) state plan amendment. Also, in order for the Medicaid plan to be affordable, the benefit package may need to be less robust than traditional Medicaid benefits.
Both strategies would require state Medicaid and insurance agencies to coordinate closely. Key advantages of Medicaid buy-in proposals include:
- The statewide nature of Medicaid’s provider networks;
- The reach of the program overall; and
- States would have the flexibility to set plan rates.
Potential disadvantages include:
- Medicaid’s lower provider reimbursement rates could diminish provider participation; and
- In some states, it may not be politically feasible to broaden the scope of Medicaid, even if individuals are required to pay premiums for coverage.
State and Federal Action on Medicaid Buy-in
Some states have already moved forward on these concepts . In early 2017, Nevada state Rep. Mike Sprinkle introduced and the state Legislature passed AB 374, which offered a public option on the marketplace. The bill directed the state to contract with insurers to provide a commercial health plan based on Medicaid (though without non-emergency medical transportation coverage), and allow eligible individuals to use ACA’s tax credits to purchase this coverage. While the proposal may have required both a 1332 and a Section 1115 Medicaid waivers, the bill was ultimately vetoed by the governor. If re-elected, Sprinkle indicated he will reintroduce the proposal.
In Minnesota, a bill was introduced in January 2017 that would have allowed individuals with incomes above 200 percent of the federal poverty level (FPL) to purchase coverage through MinnesotaCare, the state’s BHP, and they would have received a tax credit subsidy if eligible. The bill did not move forward in the state Legislature.
In Massachusetts, a provision in a recent bill that passed the state Senate in November proposes to allow any individual to purchase coverage through the state’s Medicaid program.
On the federal level, Sen. Brian Schatz (D-HI) and Rep. Ben Ray Lujan (D-NM) in October introduced the State Public Option Act in the Senate and the House, which would allow states to create a Medicaid buy-in program for all residents earning any income level who are not currently eligible for the program.
Idaho’s Health Care Plan
Idaho did not implement the ACA’s Medicaid expansion, but the state has held many meetings since passage of the ACA to explore alternative options to provide coverage to low-income individuals. Most recently, and as discussed at a NASHP conference session, the Governor’s Health Care Advisory Panel has proposed the Idaho Health Care Plan, designed to both stabilize the individual insurance market and offer coverage to some uninsured individuals.
Specifically, one aspect of the plan permits working individuals with taxable income below 100 percent of FPL to purchase subsidized marketplace coverage. The state estimates that 22,000 of the 78,000 uninsured residents with incomes under 100 percent of FPL would be able to purchase coverage.
The other component of Idaho’s proposal creates a new Medicaid Complex Medical Needs program that allows adults and children with certain complex health conditions with incomes up to 400 percent of FPL to be covered by Medicaid. Individuals would qualify if they were not eligible for Medicaid and did not have access to affordable employer coverage.
The state anticipates that moving individuals with high-cost care needs to Medicaid could reduce premiums in the marketplace and would offer these individuals more comprehensive coverage to meet their needs. The draft waiver indicates that the program would cover individuals in need of ongoing medical support for genetic conditions such as hemophilia or cystic fibrosis as well as individuals with end–of-life care needs. Most enrollees with incomes above 150 percent of FPL would be required to pay premiums for this coverage based on a sliding scale.
The two-pronged plan would require federal approval through both a 1332 waiver and a Section 1115 Medicaid waiver. The state held public hearings in December 2017 and is seeking public comments through Dec. 15, 2017. Idaho’s goal is to implement the plan in mid-2018.
Also in 2018, while there may be new efforts in Congress to modify or repeal the ACA, some states are likely to continue to pursue their own options to provide health coverage to residents. NASHP will continue to monitor and share information about these emerging state health policy proposals.
How States Can Avoid Dormant Commerce Clause Legal Challenges When Regulating Drug Costs
New state laws designed to control the costs of brand-name and generic prescription drugs often face legal challenges from the pharmaceutical industry. These lawsuits can vary depending on the individual state law, but recent industry lawsuits analyzed by the National Academy for State Health Policy (NASHP) share a common legal thread – drug manufacturers and their trade organizations contend these new state laws violate the federal Dormant Commerce Clause (DCC) case law.
The Constitution’s Interstate Commerce Clause gives Congress the authority to regulate commerce between states, and industry lawsuits have created a body of federal case law that guides what states may and may not do to interstate commerce. Essentially, federal case law has created DCC to make sure states don’t create policies that have the unintended consequence of hindering, affecting, or shaping industry business practices in other states, or that “unduly burden” the multi-state operations of national businesses. This issue – the extent to which a state law or policy can impinge on federal interstate commerce authority – has been shaped by years of federal court cases.
The pharmaceutical industry has used DCC as one way to challenge recent state laws that attempt to eradicate price gouging or bring more transparency to how the industry establishes drug prices. Here are two examples of legislation that pharmaceutical trade groups are now challenging:
- Maryland’s anti-price gouging law: Earlier this year, Maryland became the first state to enact a law protecting consumers from generic prescription drug price-gouging. The law, which went into effect Oct. 1, 2017, prevents manufacturers of generic and off-patent drugs from price gouging or imposing “excessive and not justified” increases in drug prices.
In July, the Association for Accessible Medicines, the trade association that represents generic and biosimilar drugs, filed a lawsuit charging that the law was unconstitutional.
- Nevada’s drug transparency law: Among other provisions, a new Nevada law aims to bring transparency to diabetes drug pricing by forcing manufacturers to provide information about the costs of manufacturing and marketing diabetes drugs, including company’s profits. Two pharmaceutical industry trade groups have filed a lawsuit to block the recently-enacted law, arguing it is unconstitutional.
In the cases of both Maryland and Nevada, the industry has alleged that these laws have ripple effects impacting how the industry conducts business in other states. A judge has already ruled against the industry’s DCC complaint in Maryland. The Maryland Attorney General’s response to the industry lawsuit is an important read for any state policymaker concerned about the industry’s potential legal challenges.
The Pharmaceutical Research and Manufacturers of America and the Biotechnology Innovation Organization filed a lawsuit against Nevada’s law in September, arguing the new law is preempted by federal statute and is unconstitutional. While the final outcome of the various legal aspects of the court challenges in Nevada and Maryland are not known yet, the decisions will shape how states approach drug cost control policies.
In the meantime, NASHP believes states can craft strong and effective drug cost regulations that have good potential to avoid an industry challenge based on the DCC. There may, however, be other legal challenges to these laws, even if DCC is not invoked in the legal challenges.
NASHP’s white paper by Anna Zaret and Darien Shanske provides insight and analysis to explain the issues in DCC case law that will help states craft policy that avoids running afoul of existing DCC case law. In addition to the paper, NASHP has a table featuring policy guidelines (see below) that state policymakers can consider as they develop drug cost policies.
NASHP also has a longer DCC research document available to state officials only upon request. For a copy of that DCC white paper, please contact Jennifer Reck.
Nevada – Medical Homes
Federal Support: Nevada has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Last Updated: April 2014
Nevada
In Nevada:
- Physical health services are delivered through managed care organizations (MCOs) and on a fee-for-service basis. The MCO program operates only in Clark County (Las Vegas) and urban Washoe County (Reno). In these areas children and adults who qualify for Medicaid because they belong to an income-eligible family are required to enroll into one of two MCOs, as are children who participate in the Child Health Assurance Program (CHAP). A few groups within these broad categories may choose between an MCO and fee-for-service, including children with special health care needs and severely emotionally disturbed children. There were 297,640 eligibles receiving Medicaid as of July 2011. Of these 168,851were enrolled in MCOs. The remainder received physical health services through fee-for-service.
- Mental health and substance abuse services are delivered through MCOs to beneficiaries enrolled in MCOs, and all others receive these services through fee-for-service. In addition, children and adults with significant behavioral health needs may disenroll from their MCO at any time.
- Most dental services are delivered through MCOs to beneficiaries enrolled in MCOs, while all others receive these services on a fee-for-service basis. Orthodontic services, however, are delivered on a fee-for-service basis to all beneficiaries, including those enrolled in MCOs.
- Non-emergency transportation services are delivered through a Pre-paid Ambulatory Health Plan (PAHP) that operates statewide and delivers only transportation services. Nevada reported that, in July 2011, 248,819 beneficiaries were enrolled in this PAHP.
As of 2012, 258,261 individuals (aged 0 – 20) were eligible for Nevada Healthy Kids, Nevada’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Nevada Healthy Kids achieved a screening ratio of 90%. Additionally, 93,765 eligibles received dental services, with 85,244 receiving preventive dental services.
Last updated December 2013.
| Medical Necessity |
Nevada’s Medicaid Services Manual defines medical necessity as:
“A health care service or product that is provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: diagnose, treat or prevent illness or disease; regain functional capacity; or reduce or ameliorate effects of an illness, injury or disability.
The determination of medical necessity is made on the basis of the individual case and takes into account:
Medical Necessity shall take into account the ability of the service to allow recipients to remain in a community based setting, when such a setting is safe, and there is no less costly, more conservative or more effective setting. “
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| Initiatives to Improve Access |
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| Reporting & Data Collection |
Nevada is modifying its Medicaid Management Information System (MMIS). As part of a long-range effort, EPSDT staff have developed an electronic version of an EPSDT screening form. Eventually, the form will be completed online and the information will be fed directly into the MMIS system.
Managed care organizations (MCOs) in Nevada are required to report on child-specific performance measures. They can receive incentive payments (see page 11) based on performance on Health Effectiveness Data and Information Set (HEDIS) measures for well-child visits and childhood immunization status. They must also report on a non-incentive measure for children and adolescents’ access to primary care practitioners.
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| Behavioral Health |
In late 2011 Nevada Medicaid implemented payment for developmental screens (including those that focus on social/emotional development) billed under CPT code 96110 in their state (See Nevada EPSDT Provider Manual, Section 1503.3A(2)). Providers must use a valid, standardized developmental screening tool. While Nevada does not include a list of tools they do explicitly reference the AAP’s policy that establishes criteria for screening tools. Nevada has also developed EPSDT well child visit forms that prompt pediatricians to use a validated developmental screening tool, and to identify which tool was used.
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| Support to Providers and Families |
Nevada Medicaid has produced a number of handouts and brochures on the EPSDT benefit for families and for providers as part of a Healthy Kids Toolkit. The toolkit contains information on screening schedules, BMI Growth Charts, immunization schedules, lead poisoning and development screening, oral health, billing information, and other resources.
EPSDT Screening Form Guidelines provide direction to physicians on use of the state’s EPSDT well child visit forms.
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| Care Coordination |
Nevada has begun work to track referrals for EPSDT-eligible children using code modifiers: providers are instructed to use a specific modifier (TS) along with the well-child code to indicate that a referral or follow up is needed.
Managed care contracts in the state require managed care organizations (MCOs) to “put a basic system in place, which promotes continuity of care and case management.” Under this continuity of care system, MCOs must have partnerships with primary care providers and specialists to “holistically address members’ health needs.” The contracts specify that “care coordination must include not only the specific diagnosis, but also the complexities of multiple co-morbid conditions, including behavioral health, and related issues such as the lack of social or family support.”
Nevada Medicaid is currently in the process of seeking approval from CMS for a section 1115 waiver. The 1115 waiver is designed to encompass all services and eligible populations under a single authority that will provide the state broad flexibility to manage Medicaid and CHIP more efficiently. Through the use of the 1115 waiver, Nevada Medicaid intends to phase in managed care for all eligible recipients. As a part of its waiver initiative, Nevada Medicaid plans to implement medical homes and health homes for non-MCO enrollees, including those with chronic conditions, severe mental health issues, or patterns of utilization that indicate the enrollee may benefit from case management.
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| Oral Health |
Nevada delivers most oral health services through MCOs to children enrolled in these plans; the remainder receive the services through fee-for-service. Orthodontia is carved out of the MCO contract and all children receive those services through fee-for-service—all orthodontia services require prior authorization (see 1003.9 of the dental handbook.)
Nevada Medicaid reimburses for fluoride varnish provided by physicians and other providers who administer Healthy Kids screens (e.g., Federally Qualified Health Centers).
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Nevada 2014 CHIP Fact Sheet
2014 NASHP CHIP Fact Sheet – Nevada 
2012 NASHP CHIP Fact Sheet – Nevada
2010 NASHP CHIP Fact Sheet – Nevada
2008 NASHP CHIP Fact Sheet – Nevada
2012 NASHP CHIP Fact Sheet – Nevada
2010 NASHP CHIP Fact Sheet – Nevada
2008 NASHP CHIP Fact Sheet – Nevada
Additional States’ CHIP Fact Sheets…
Adobe Acrobat .PDF printable versions of the Nevada NASHP CHIP Fact Sheets
Key Highlights:
Program Type: Nevada operates a combination CHIP program, called Check Up.
Number of Children Covered: In FY2013, 20,277 children were covered by Check Up.*
State’s Enhanced Federal Match Rate: For FY2014, the federal match is 74.17% and for FY2015 it is 75.05%.
*Data from Medicaid and CHIP Payment and Access Commission March 2014 MACStats report. Nevada was a combination program in FY2013 but did not report any Medicaid-expansion enrollees.
The Children’s Health Insurance Program (CHIP) was created in 1997 to provide quality health coverage for children under 19 in families that earned too much to qualify for Medicaid but were unable to afford coverage in the private market. Each state has the option to cover its CHIP population under its Medicaid program, design and structure a separate CHIP program, or establish a combination program using both options.
The Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 strengthened the program through increased federal funding, new outreach and enrollment opportunities, mental health parity, the requirement to cover dental care, and other provisions. In 2010, the Affordable Care Act (ACA) extended CHIP funding through federal fiscal year 2015 and required states to maintain Medicaid and CHIP eligibility levels and processes for children through 2019.1
Participation Rate: 69.8% of eligible children in Nevada participated in either Medicaid or Check Up in 2011, the last year for which we have national data. The national average was 87.2% in 2011.2
Eligibility Levels: States establish CHIP eligibility levels within federal rules. Under the ACA’s maintenance of effort requirement, they must maintain CHIP eligibility levels they had in place when ACA was enacted until September 30, 2019. Beginning in 2014, eligibility levels for CHIP were revised based on Modified Adjusted Gross Income (MAGI).
| Modified Adjusted Gross Income (MAGI) Eligibility Levels for CHIP in Nevada (by Age Group) in 2014 | ||
| Ages 0 – 1 | Ages 1 – 5 | Ages 6 – 18 |
| 161-200% FPL | 161-200% FPL | 134-200% FPL |
Notes: Under ACA, states must cover all children with incomes up to 133% FPL in Medicaid, but if they had been covered in CHIP (Title XXI) prior to 2014, the state still receives the Title XXI match. Eligibility levels do not include the mandatory 5% income disregard. Data from CMS eligibility table.
Benefit Package: States that operate Medicaid expansion CHIP programs must follow Medicaid rules, including providing all Medicaid covered benefits to enrolled children. In separate CHIP programs, states have substantial flexibility in designing CHIP benefit packages within broad federal guidelines. In addition to general medical and dental benefits, other benefits offered in Nevada’s CHIP program include (but are not necessarily limited to):
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Delivery System: The provider network in Check Up is the same as Medicaid. Managed care is offered in urban areas, while fee-for-service is offered in all other regions. Newborns are enrolled in their mother’s or family’s managed care.
Premiums & Cost Sharing: Within federal parameters, states can set CHIP program premium and cost sharing levels. In total, any family contribution to the cost of coverage cannot exceed five percent of family income.
| Premiums and Selected Cost Sharing in Check Up, 2013 | ||||
| Family Income Level | Premiums | Office Visits | Inpatient Services | Prescription Drugs |
| 36-150% FPL | $25 per quarter, per family | None | None | None |
| 151-175% FPL | $50 per quarter, per family | None | None | None |
| 176-200% FPL | $80 per quarter, per family | None | None | None |
Note: MAGI-adjusted income levels for premiums and cost sharing were not available at the time of publication.
Efforts to Simplify Enrollment and Renewals: CHIPRA established a five-year incentive program to support state efforts to simplify enrollment and renewal of eligible children in Medicaid and CHIP.3 From FY2009 – FY2013, Nevada did not qualify for incentive payments.4
| Enrollment and Renewal Strategies Implemented in Nevada, as of December 2013 | ||||
| Strategy |
Used |
Strategy |
Used |
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| Elimination of in-person interview* |
✓ |
Use of presumptive eligibility |
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| Elimination of asset test* |
✓ |
Use of 12-month continuous eligibility |
✓ |
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| Use of joint application and renewal forms* |
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Use of express lane eligibility |
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| Automatic/Administrative renewal* |
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Premium assistance |
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*ACA requires states to implement this strategy beginning January 2014. For definitions of strategies in this chart, see the Centers for Medicare and Medicaid Services December 2009 State Health Official letter.
Other Program Characteristics: Below are some other key program characteristics of Check Up.
| Does Nevada… | |
| Require a waiting period?5 | No (as of 1/1/14)6 |
| Offer a buy-in option?7 | No |
| Cover dependents of public employees?8 | No |
| Cover lawfully residing children without a five-year waiting period?9 | No |
Quality Measures: States may report on a “core set” of quality measures for children. Nevada reported on 9 measures for federal fiscal year 2012. Among the measures is access to primary care providers, listed below.
| Percentage of Children and Adolescents Visiting a Primary Care Provider, by Age (FFY 2012) | ||||
|
12-24 month |
25 months – 6 years |
7-11 years |
12-19 years |
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| Nevada |
98.1% |
93.9% |
94.4% |
92.5% |
Source: Department of Health and Human Services, 2013 Annual Report on the Quality of Care for Children in Medicaid and CHIP, September 2013. The measure is for the percentage of children ages 12 to 24 months and 25 months to 6 years receiving a visit to a primary care provider within the past year; and every two years for children ages 7 to 11 years and 12 to 19 years. Note: These data include CHIP only.
Footnotes:
1 Information in this fact sheet has been verified by the state.
2 Genevieve Kenney et al., Medicaid/CHIP Participation Rates Among Children: An Update. September 2013. https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf407769
3 To qualify for incentive payments each fiscal year, states had to implement at least 5 out of 8 specified strategies and increase child enrollment in Medicaid above a state-specific target level.
4 InsureKidsNow.gov. “CHIPRA Performance Bonuses: A History (FY 2009 – FY 2013).” https://www.insurekidsnow.gov/professionals/eligibility/pb-2013-chart.pdf
5 States may implement waiting periods up to 90 days in CHIP. A waiting period is the length of time a child must be uninsured before s/he can enroll in CHIP.
6 Information on waiting periods verified by state. Prior to January 2014, Check Up had a six-month waiting period.
7 States can allow families with incomes above the upper income eligibility limit to pay the full cost to purchase coverage for their uninsured children through CHIP.
8 CHIPRA provided states the option to cover the income-eligible dependents of state employees under CHIP.
9 CHIPRA provided states the option to remove the five-year waiting period for lawfully residing children.
Nevada
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email skinsler@oldsite.nashp.org.
Last updated: October 2012
Supporting Behavioral Health for Older Adults: State Medicaid Strategies
Download the slides (PDF)
The special behavioral health needs of older adults are a growing concern for state Medicaid programs. In meeting this challenge, states are frequently turning to existing state Medicaid options to provide cost effective, specialized services and supports for older adults with behavioral health needs. On this webinar, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) through Abt Associates, presenters from three states will highlight tools and strategies being used in their states’ Medicaid program to address the specialized behavioral health needs of older adults.
Presenters:
- Deborah Baldwin, Acting Branch Chief, Substance Abuse and Mental Health Services Administration
- William Boyer, Pennsylvania Office of Mental Health and Substance Abuse Services
- Dave Caloiaro, Nevada Division of Mental Health and Developmental Services
- Traci Adair, Washington Aging and Disability Services Administration
| Webinar_summary.pdf | 158 KB |
| Supporting_Behavioral_Health_for_Older_Adults_agenda.pdf | 143.5 KB |
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
