Frequently Asked Questions

What are the Essential Health Benefits (EHB) in Nevada?

All new products and modifications to existing products in the individual and small group markets must now comply with a set of benefits. These benefits are defined by the selection of a specific plan by the Commissioner of Insurance.  The ACA established ten areas that must be addressed and that, combined with Nevada’s set of Mandated Benefits, creates the core of the EHB. However, the specific level of coverage is determined by the Health Plan of Nevada’s POS plan that was selected in December 2012.

Which federally required EHBs are most noteworthy?

The ACA defined ten categories that must be offered by health care products beginning in 2014.  The list covers the basic anticipated coverage but also includes mental health and substance abuse treatment, rehabilitation and habilitative services, pediatric care and preventive services.

Which EHBs are mandated by the State of Nevada?

Over the last three decades Nevada has enacted mandated health benefits to ensure that consumers have guaranteed coverage of selected ailments.  Primary among those covered include, autism spectrum disorders, prostate cancer screening, diabetes management and treatment, hospice services, PKU diet coverage, TMJ treatment and many others. 

What changes occurred on January 1, 2014 under the Affordable Care Act?

Many significant parts of the ACA take effect, including the individual mandate that is considered the cornerstone innovation of the law.  The act makes everyone eligible for coverage regardless of health status.  Additionally, the essential health benefits are now required.

Which health care products does the DOI review?

The Nevada Division of Insurance is charged with protecting the rights of the Nevada consumer and the public’s interest in dealing with the insurance industry. The Life and Health section of the Division is responsible for the approval, disapproval or modification of all health insurance products rates and forms in the individual and the small group markets and all health insurance product forms in the large group market. 

How is my premium determined?

In the individual market your premium is the result of the application of personal factors to a plan's basic rate; such as your age, the level of coverage, where you live in Nevada and whether you are a tobacco user (see "How does the rate differ from the premium?" below).  For small group policies the level of coverage may be chosen by your employer and the location of the business takes priority over your home address.  The plan’s rate is adapted to your unique situation to create your premium.

What is driving the health insurance rates higher?

Simply stated the rates change in response to two factors; costs and utilization.  As the price or cost of care increases, whether from technological changes or inflationary pressures,  the rates must increase to cover the change.  Similarly, if even the costs remain the same but the services are utilized more often, future rate adjustments will be made to cover the increased utilization. 

What is the Medical Loss Ratio?

One of the primary industry financial measurement tools is the Medical Loss Ratio or MLR.  The MLR is essentially how much of the insurer’s revenue is spent on claims.  The ACA has mandated that a minimum of 80 percent of premiums be spent on claims and wellness.  If a carrier fails to meet that level the difference must be refunded to the policyholders in cash or a reduction of future premiums.  The large group market is also bound by an even greater MLR of 85 percent with refunds also required if not met.

Explain the different metallic levels

This is a scale developed to indicate the ratio of medical costs borne by the insurance company and the policyholder.  Generally speaking, a bronze policyholder must cover about 40 percent of his or her medical bills, a silver plan drops to 30 percent, a gold plan 20 percent and the greatest coverage is under a platinum plan that policyholders pay 10 percent of all medical costs in addition to the premium.

How can I learn more about health insurance?

Visit the Consumer Services section of our website, or the U.S Department of Health and Human Resources’ Healthcare.gov offers a primer at healthcare.gov/health-insurance-basics/.

How can I comment on rate increase requests by insurers?

Filings and plans are available for your comments on the Division of Insurance website.  A brief consumer friendly explanation of the rate request will accompany each filing and the plan documents including the Schedule of Benefits and Evidence of Coverage will also be available for review.  All comments will be reviewed and made public if you so desire.

Where does my premium dollar go?

A rough breakdown of your Nevada premium dollar in 2013 was: 81 cents to medical claims, 8 cents for general and administrative expenses, 4.5 cents for state and federal taxes, 2.5 cents for profit (most of which is retained in the business), 3 cents for sales commissions and a penny for wellness and other similar programs.

Can I qualify for subsidies?

For the individual market if your income is 133 percent (or less) of the federal poverty level, then you will qualify for Medicaid.  Between 134 percent and 400 percent of the federal poverty level a graduated subsidy is available.

Can I qualify for business tax credits?

A small business may qualify for tax credits if it has fewer than 25 full-time equivalent employees with an average annual wage under $50,000 and the employer covers at least half of the insurance premium for the employees. 

How does the rate differ from the premium?

The “rate” is the term for a health insurance product’s base standard from which a specific “premium” may be calculated.   The base rate is adjusted by age, location and family factors to determine the unique premium for an individual, family or small business. Tobacco users may also incur premiums up to 50% above the base rate.

What actions can the DOI take on rate increase requests?

The Nevada Division of Insurance has three possible determinations for a rate increase request; we can approve, disapprove or modify.  The process is initiated with a thorough analysis which often includes a discussion with the carrier and request for additional information/justification before the final judgment is rendered. An insurer may appeal a decision by requesting a formal hearing before the Commissioner of Insurance.

Are there premium penalties for smokers?

The Affordable Care Act permits up to a 50 percent surcharge for a tobacco user’s premium above the non-user.  Each carrier can select their own penalty that can be further modified by a unique age curve for the tobacco user.

What coverage do I have when I am traveling?

Two aspects of this issue are important to remember, first in an emergency your policy must cover the care whether it occurs within or outside of the provider network defined in your policy. Although emergency care outside of your provider network may be covered your out of pocket costs may be higher. Secondly, not all policies cover non-urgent care outside of the provider network defined in your policy.  Carefully acquaint yourself with the policy limitations prior to purchase.

Is dental coverage now included with health insurance?

Children’s (pediatric) dental coverage is not required under the health exchanges but can be purchased as a stand-alone product.  Policies sold outside the health exchange are required to include pediatric dental unless the carrier obtains reasonable assurance that certified stand-alone dental coverage has been obtained. Adult dental coverage is an optional purchase whether through the exchange or in the open market.

Where can I go for advice on purchasing health insurance?

You may utilize the expertise of a licensed agent, broker or insurer and utilize their services in the selection of health insurance. Exchange Enrollment Facilitators will be employed by the Exchange to provide guidance and assistance in the selection and purchase of health insurance. They will be certified by the Nevada Division of Insurance which will indicate that they have met the minimum competency requirements to perform these tasks.

Remember to always verify with the Nevada Division of Insurance that the person or company you are working with is licensed, certified or authorized to conduct business in this state. You can do this at doi.nv.gov/licensing-search or you can contact the Division in Northern Nevada at (775) 687-0700 and in Southern Nevada at (702) 486-4009.

The Nevada Division of Insurance has a wealth of information available on its website to help you make your health insurance decisions.

Should I buy from the Nevada Health Link or outside the exchange?

If you qualify for a federal subsidy, you must go to the exchange to receive that assistance.  If you do not qualify for subsidies the exchange versus the open market is a personal decision.  The Division recommends that you research both options and see what best fits your own particular situation.

How do I know which “Network” is best for me?

You should look for a network that is accessible for your healthcare needs.  Secondarily, you might have a special medical issue or specific drug that is better represented under one drug formulary over another product's formulary.  Research the networks and drug formularies available to you and attempt to maximize your coverage and convenience.

What are the preventive benefits under a plan?

The covered preventive benefits can vary slightly from plan to plan but most will cover at no charge (within network) a minimum of the following:

  • Colorectal Cancer screenings with polyp removal for those over 50
  • Immunizations and vaccines for children and adults
  • Smoking cessation counseling
  • Mammograms and cervical cancer screenings for women
  • Wellness checkups for babies and children

You can read more about preventive benefits here.

How often can my premium be increased?

The ACA does not allow individual policy rates to be altered for the year of purchase which will always be a calendar year from January to December.  Small group rates for small businesses (2-50 employees) are fixed for the policy year.  A carrier's small group rates can be adjusted quarterly, but that only applies to those businesses purchasing new coverage during that quarter and then those rates are good for that small employer for a year.

Why are large group rates excluded from the ACA and DOI rate review?

Large group health insurance rates represent the largest percentage of coverage in the United States.  That coverage is, in most cases, highly researched, toughly negotiated and competitively sought after by a number of insurers.  Those competitive pressures are believed to provide adequate protection for the purchasers of large group plans and no further governmental involvement is required.

What is the difference between an HMO, POS or PPO plan?

Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point-of-Service Plans (POS) are all types of managed health care.

An HMO requires you to select a Primary Care Physician (PCP) within the HMO network. In most cases, care will be restricted to the HMO network and you must be referred by your PCP before seeing a specialist.  Traditionally, out of pocket costs are in the form of copayments, however some HMO plans have coinsurance as well as annual deductibles. 

With a PPO, you can see providers both inside and outside the PPO network, and refer yourself to a specialist.  However, seeing providers outside the PPO network may result in you paying a larger share of the cost to receive those services.  Most plans require an annual deductible be satisfied before the plan pays any cost share.

A POS is typically an HMO plan that is a combination of an HMO and PPO plans with benefit levels that vary depending on whether you receive care in or out of the carrier's network(s) of providers.  POS plans may require you to designate an in network physician to be your PCP and if you choose to go out of network, you will have greater out of pocket costs.