Transfer of Power: Impact on Nevada’s Health Care System Mike Willden Chief of Staff to Governor Brian Sandoval State of Nevada, Office of Governor Brian Sandoval
Transfer Process September 1 – Agency Request budgets due October 15 – Agency Request (revised) becomes public November 6 – Election Day December 1 – Base budget due to Legislative Fiscal December 5 – Economic Forum Meeting January 2019 – State of the State January 2019 – 2020/2021 budget released February 4 – 2019 (80 th session) Nevada Legislature begins State of Nevada, Office of Governor Brian Sandoval 2
Transfer Issues/Concerns Health care philosophy of new Governor Available funding to sustain or grow programs Key executive appointments Retirements/turnovers Federal instability State of Nevada, Office of Governor Brian Sandoval 3
Revenue / General Fund 2 x CAP = $8.1 billion Economic Forum forecast (December 2018) Big Ten Performance: Order Tax Value / Forecast Performance 1 Sales Tax $1.154 billion Below 1.3% Above 1.5% 2 Gaming percent fees $757 million 3 Modified Business Tax (MBT) $641 million Equal 0.1% 4 Insurance Premium Tax $396 million Above 3.9% 5 Commerce Tax $186 million Below 2.7% (FY17) 6 Cigarette Tax $173 million Below 6.8% Live Entertainment Tax (gaming and non- 7 $133 million Below 4.0% gaming) 8 Business License Fee (BLF) $106 million Above 3.5% Above 15.2% 9 Real Property Transfer Tax $87 million Above 2.6% 10 Commercial Recordings $75 million State of Nevada, Office of Governor Brian Sandoval 4
Revenue Items to Watch Is the Commerce Tax in or out? (5 th largest tax to the General Fund) Insurance Premium Tax Performance $5 million Home Office Credit expires December 31, 2020 Medicaid Managed Care Silver State Health Insurance Exchange Government Service Tax (GST) reverts to the Highway Fund ($20 million/year) Sales Tax Variables Wayfair decision impact/online sales (October 1 implementation by regulation) Sales Tax Exemptions (medical supplies and feminine hygiene products) Tax Credits (used and unused) Tesla credits end ($195 million available already earned) Film Tax Commerce Tax Credits against MBT Marijuana Taxes (15% wholesale to schools [$27 million]) and 10% retail to the Rainy Day Fund [$43 million]) State of Nevada, Office of Governor Brian Sandoval 5
Fiscal Year 2018: $69.8 million in excise tax collection vs. $50.3 million projected Credit: Nevada Department of Taxation State of Nevada, Office of Governor Brian Sandoval 6
Last four months of tax revenue collections were the largest months in fiscal year 2018 *No revenue estimated in recreational market for July 2017 due to uncertainty of local governments issuing permits before July 1 st Credit: Nevada Department of Taxation State of Nevada, Office of Governor Brian Sandoval 7
15% wholesale marijuana tax revenues were more than $3 million for June Above forecast and trending upward *No revenue estimated in recreational market for July 2017 due to uncertainty of local governments issuing permits before July 1 st Credit: Nevada Department of Taxation State of Nevada, Office of Governor Brian Sandoval 8
10% retail marijuana tax revenues were more than $4.5 million for June Coming in well above projections *No revenue estimated in recreational market for July 2017 due to uncertainty of local governments issuing permits before July 1 st Credit: Nevada Department of Taxation State of Nevada, Office of Governor Brian Sandoval 9
Insurance Coverage Status State of Nevada, Office of Governor Brian Sandoval
Percentage of People without Health Insurance Coverage: 2013 to 2016 25% 20.7% 20% 15.2% 14.5% 15% 12.3% 11.7% 11.4% 9.4% 10% 8.6% 5% 0% 2013 2014 2015 2016 Nevada United States Credit: United States Census Bureau State of Nevada, Office of Governor Brian Sandoval 11
2018 Health Insurance Coverage by Source Estimated Member Count as a Percentage Population / Coverage Category Member Count of Total State Population Total Estimated Population in Nevada 100% 2,959,801 Individual Market 125,915 4% Small Group Market 95,879 3% Large Group Market (Fully Insured) 390,000 13% Group Market (Self Funded) 905,227 31% Medicaid / CHIP 651,751 22% Medicare 353,868 12% Tricare/ VA Health Care (other public) 118,392 4% Uninsured Estimate 318,768 11% Total Covered Population 2,641,033 89% Credit: Nevada Division of Insurance State of Nevada, Office of Governor Brian Sandoval 12
2018 Health Insurance Coverage by Source Individual Market Small Group Market 4% 3% Tricare/ VA Health Care (other public) Uninsured Estimate 4% 11% Large Group Market (Fully Insured) Medicare 13% 12% Group Market (Self Funded) Medicaid / CHIP 31% 22% Credit: Nevada Division of Insurance State of Nevada, Office of Governor Brian Sandoval 13
Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval
Silver State Health Insurance Exchange The Silver State Health Insurance Exchange was established by the State of Nevada in 2011, and operations began in 2013, with the belief that all Nevadans deserve access to health insurance. Nevada Health Link, the state-based online marketplace, supported by healthcare.gov, allows Nevadans to shop for health insurance and provides federal tax credits and subsidies to help cover the cost of insurance for those who qualify. Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 15
Silver State Health Insurance Exchange • The Exchange connects Nevadans who are not insured by their employer, Medicaid or Medicare to health insurance • Individuals can purchase Affordable Care Act-certified Qualified Health Plans through the Exchange. If eligible, they can receive subsidy assistance to help offset monthly premium costs • The Exchange uses a hybrid model state-based online marketplace that utilizes the federal platform, healthcare.gov • It is solely self-funded and no state or federal funds support operations Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 16
Year-over-Year Health Exchange Enrollment 100,000 91,003 89,061 88,145 90,000 80,000 73,596 70,000 60,000 50,000 38,000 40,000 30,000 20,000 10,000 0 2014 2015 2016 2017 2018 Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 17
2018 Enrollment Geography Note: Centers for Medicare & Medicaid Services policy is to redact exact counts for zip codes with fewer than 10 plan selections. As a result, the county-by-county figures listed above represent 264 fewer plan selections than the statewide total of 91,003. Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 18
Health Exchange Enrollment by Age Age ≥65 2% Age < 18 15% Age 55-64 26% Age 18-25 8% Age 26-34 16% Age 45-54 18% Age 35-44 15% Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 19
2018 Enrollment Plan Selections Exchange Premiums and Financial Assistance: • Average monthly premium per person for all consumers = $515 • Average monthly premium after Advance Premium Tax Credit (APTC) for all consumers = $151 • 82.1% = percent of plan selections with APTC • Average APTC allocated to each individual for consumers with an allocated APTC greater than $0 = $444 • 48.4% = percent of plan selections with Cost Sharing Reduction Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 20
GetInsured Nevada Health Link recently awarded GetInsured (Vimo, Inc.) a contract to operate its technology platform for eligibility, enrollment and a consumer assistance center when Nevada transitions to a state- based Exchange in November 2019. Nevada Health Link currently leases the healthcare.gov platform to facilitate the sale of qualified health plans and will continue to do so through plan year 2019. The Exchange intends to be fully transitioned to a state-based system by November 1, 2019, in time for plan year 2020. GetInsured operates in seven states: Idaho California Connecticut Minnesota Mississippi New Mexico Washington Credit: Silver State Health Insurance Exchange State of Nevada, Office of Governor Brian Sandoval 21
Medicaid Caseload growth FMAP impact Spending trends State of Nevada, Office of Governor Brian Sandoval
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