Nevada's plan to launch a public option health plan hinges on participation from the state's Medicaid managed care organizations.
After passing both houses of the legislature, Democratic Gov. Steve Sisolak told reporters Tuesday he will sign the bill that will likely crown Nevada as the second state to pass a public option — a government-run plan that promises to lower premiums and increase access to care by creating an additional insurance option for residents.
To achieve its aims, Nevada's public option plan requires premiums to be 5% lower than the benchmark silver Affordable Care Act plan in each ZIP code and, ultimately, premiums must be reduced by 15% over a four-year period. At the same time, reimbursement to providers must not go below Medicare rates.
Coverage under the public option would begin in 2026. The bill is just the beginning of a process in which Nevada will seek a waiver from the federal government to enact the public option plan. In short, the state is asking to capture the savings it may generate for the federal government.
Similar to other public health programs, the state of Nevada will bid out the public option business to insurance carriers instead of doing the work in-house. The state will rely heavily on Medicaid managed care organizations, at least at first, as it tries to spur participation.
"As a condition of continued participation in any Medicaid managed care program," Medicaid MCOs will be forced to offer a public option plan if they want a Medicaid contract with the state, according to the bill sponsored by a Democratic state senator and Nevada's majority leader, Nicole Cannizzaro, which passed the body earlier this week.
The bill says Medicaid MCOs must submit a "good faith proposal," in response to an eventual RFP.
Sabrina Corlette, a research professor at Georgetown's Center on Health Insurance Reforms, said she "assumed they wanted a guaranteed pool of potential bidders for the public option. Maybe they were afraid that if they didn't require some bidders, they might not get any."
Currently, there are three Medicaid MCOs in the state of Nevada: Centene, UnitedHealthcare and Anthem Blue Cross Blue Shield.
None of the companies responded to a request for comment.
The Nevada bill comes at a time when there is a renewed interest at the federal level for a public option plan, and a push from a handful of other states interested in creating an affordable health plan option for residents who have found themselves ineligible for Medicaid but unable to afford a marketplace plan.
Washington was the first state to implement a public option plan, which went live this year.
President Joe Biden is a proponent of a public option plan — instead of "Medicare for All" — as it would build on the ACA, a law he helped usher in under former President Barack Obama, instead of dismantle it.
The insurance lobby is strongly opposed to a public option and previously expressed concern over Nevada's plan via an opposition letter dated May 3 and addressed to Cannizzaro and the state's Health and Human Services Committee.
AHIP, America's Health Insurance Plans, took aim at the way in which the bill requires premiums for the public option plan to be lower than certain competitive plans on the exchange. AHIP characterized it as arbitrary "government rate setting."
The tactic of prodding insurers into offering a separate business line in a specific state is not new.
The exchanges, launched under the ACA, relied on insurers to voluntarily sell plans to a relatively new market. At times, some counties were at risk of having no exchange plan at all. Some states tried to alleviate this problem by creating incentives for Medicaid MCOs if they also offered an exchange plan.
In a more extreme example, New York banned insurers from providing plans to any other program, including Medicaid, if they exited the exchange, according to a 2017 executive order from Gov. Andrew Cuomo.
Over time, the exchanges have become a core business for Medicaid MCOs.
Selling exchange plans is a complementary business for Medicaid MCOs that traditionally contract with states to care for Medicaid-eligible members. By selling exchange plans, Medicaid MCOs attempt to attract the Medicaid members they were serving as they churn off the program as their income fluctuates. It's a key strategy for players like Centene.
However, if they're forced to participate in the public option plan they will have to undercut their own premium prices on the exchange.
In Nevada, UnitedHealthcare and Centene command the largest market share on the exchange, according to the Kaiser Family Foundation.