Frequently Asked Questions

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

All new plans and modifications to existing plans 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 through 2016 is determined by the Health Plan of Nevada’s POS plan that was selected in December 2012. The EHB Benchmark Plan for 2017 is determined by HPN's POS C-XV-500-HCR benefits. The current and 2017 benchmarks are available here.

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 for certain medical conditions.  Primary among those covered include autism spectrum disorders, prostate cancer screening, diabetes management and treatment, hospice services, PKU diet coverage, and TMJ treatment. 

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 rates and forms in the individual and the small group markets and all health insurance 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 base 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. 

What factors affect health insurance rates?

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?

The percentage of health insurance premiums that are spent by the insurance company on health care services.  The ACA requires that large group plans spend 85% of premiums on clinical services and other activities for the quality of care for enrollees.  Small group and individual market plans must devote 80% of premiums to these purposes.  Insurers that do not meet these requirements must forfeit excess premiums to their policy holders in the form of a rebate which is calculated annually.

Explain the different metallic levels

The metallic levels are an expression of the Actuarial Value (AV) of a plan.  The AV is the percentage of total average costs for covered benefits that a plan will cover.  For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all in-network covered benefits through some combination of deductibles, copays and coinsurance.  The AV is reflected in the metallic levels of coverage, Platinum at approximately 10% insured responsibility, Gold at about 20%, Silver at 30% and Bronze at 40%. 

How can I learn more about health insurance?

Continue to browse 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?

Rate filings and plans are available for your comments on the Division of Insurance website.  A brief 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.

Can I qualify for subsidies?

For the individual market if your household income is 138 percent (or less) of the federal poverty level, then you will qualify for Medicaid.  Between 139 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.  Small business tax credits are only available through the Small Business Health Options Program more commonly referred to simply as SHOP. 

How does the rate differ from the premium?

The “rate” is the term for a health insurance plan’s base rate 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 using, within the last six months, any tobacco product four or more times per week.

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 must be covered your out-of-pocket costs may be higher. Secondly, not all policies cover non-emergent care outside of the provider network defined in your policy.  It is important to understand how your policy works prior to traveling.

Is dental coverage now included with health insurance?

Children’s (pediatric) dental is not required to be covered by QHPs offered on the Exchange but can be purchased as a stand-alone product.  Policies sold outside the Exchange must cover 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 are certified by the Nevada Division of Insurance which indicates 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 needs.

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

You should look for a network that is accessible for your healthcare needs that might includes favored physicians.  Also, you might have a special medical issue that requires a specific drug that is better represented under one drug formulary over another plan's formulary.  Research the networks and drug formularies available to you and attempt to maximize your coverage and convenience. Access to all plan formularies and provider networks is available at our rate wizard.

What are the preventive benefits under a plan?

Health insurers must cover (within network) preventive benefits at no charge. The Division of Insurance provides links to the most current and extensive benefits available for women, children or adult (men and women) immunizations and the US Preventive Services Task Force 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, PPO or EPO plan?

Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point-of-Service Plans (POS), and Exclusive Provider Organization (EPO) 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.

An EPO is similar to an HMO in that the insured is required to utilize only the approved network of physicians and hospitals to receive claim coverage.  Emergency medical care is the only exception to the in-network stipulation imposed on EPO plans.

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.

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.