Transfer of Power: Impact on Nevadas Health Care System Mike - - PowerPoint PPT Presentation

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Transfer of Power: Impact on Nevadas Health Care System Mike - - PowerPoint PPT Presentation

Apr 29, 2023 486 likes •879 views

Transfer of Power: Impact on Nevadas 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

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State of Nevada, Office of Governor Brian Sandoval

Mike Willden

Chief of Staff to Governor Brian Sandoval

Transfer of Power: Impact on Nevada’s Health Care System

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Transfer Process

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State of Nevada, Office of Governor Brian Sandoval

  • 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 (80th session) Nevada Legislature begins
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Transfer Issues/Concerns

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State of Nevada, Office of Governor Brian Sandoval

  • Health care philosophy of new Governor
  • Available funding to sustain or grow programs
  • Key executive appointments
  • Retirements/turnovers
  • Federal instability
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Revenue / General Fund

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State of Nevada, Office of Governor Brian Sandoval

  • 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% 2 Gaming percent fees $757 million Above 1.5% 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% 7 Live Entertainment Tax (gaming and non- gaming) $133 million Below 4.0% 8 Business License Fee (BLF) $106 million Above 3.5% 9 Real Property Transfer Tax $87 million Above 15.2% 10 Commercial Recordings $75 million Above 2.6%

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Revenue Items to Watch

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State of Nevada, Office of Governor Brian Sandoval

  • Is the Commerce Tax in or out? (5th 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])

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Fiscal Year 2018: $69.8 million in excise tax collection vs. $50.3 million projected

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State of Nevada, Office of Governor Brian Sandoval

Credit: Nevada Department of Taxation

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Last four months of tax revenue collections were the largest months in fiscal year 2018

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State of Nevada, Office of Governor Brian Sandoval

Credit: Nevada Department of Taxation

*No revenue estimated in recreational market for July 2017 due to uncertainty of local governments issuing permits before July 1st

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15% wholesale marijuana tax revenues were more than $3 million for June Above forecast and trending upward

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State of Nevada, Office of Governor Brian Sandoval

Credit: Nevada Department of Taxation

*No revenue estimated in recreational market for July 2017 due to uncertainty of local governments issuing permits before July 1st

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10% retail marijuana tax revenues were more than $4.5 million for June Coming in well above projections

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State of Nevada, Office of Governor Brian Sandoval

Credit: Nevada Department of Taxation

*No revenue estimated in recreational market for July 2017 due to uncertainty of local governments issuing permits before July 1st

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State of Nevada, Office of Governor Brian Sandoval

Insurance Coverage Status

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Percentage of People without Health Insurance Coverage: 2013 to 2016

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State of Nevada, Office of Governor Brian Sandoval

20.7% 15.2% 12.3% 11.4% 14.5% 11.7% 9.4% 8.6% 0% 5% 10% 15% 20% 25% 2013 2014 2015 2016 Nevada United States

Credit: United States Census Bureau

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State of Nevada, Office of Governor Brian Sandoval

2018 Health Insurance Coverage by Source

Credit: Nevada Division of Insurance

Population / Coverage Category Estimated Member Count Member Count as a Percentage

  • f Total State Population

Total Estimated Population in Nevada 2,959,801 100% 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%

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Individual Market 4% Small Group Market 3% Large Group Market (Fully Insured) 13% Group Market (Self Funded) 31% Medicaid / CHIP 22% Medicare 12% Tricare/ VA Health Care (other public) 4% Uninsured Estimate 11%

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State of Nevada, Office of Governor Brian Sandoval

Credit: Nevada Division of Insurance

2018 Health Insurance Coverage by Source

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State of Nevada, Office of Governor Brian Sandoval

Silver State Health Insurance Exchange

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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.

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State of Nevada, Office of Governor Brian Sandoval

Credit: Silver State Health Insurance Exchange

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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
  • perations

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State of Nevada, Office of Governor Brian Sandoval

Credit: Silver State Health Insurance Exchange

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Year-over-Year Health Exchange Enrollment

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State of Nevada, Office of Governor Brian Sandoval

38,000 73,596 88,145 89,061 91,003 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 2014 2015 2016 2017 2018

Credit: Silver State Health Insurance Exchange

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2018 Enrollment Geography

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State of Nevada, Office of Governor Brian Sandoval

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

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Health Exchange Enrollment by Age

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State of Nevada, Office of Governor Brian Sandoval

Credit: Silver State Health Insurance Exchange

Age < 18 15% Age 18-25 8% Age 26-34 16% Age 35-44 15% Age 45-54 18% Age 55-64 26% Age ≥65 2%

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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

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State of Nevada, Office of Governor Brian Sandoval

Credit: Silver State Health Insurance Exchange

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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

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State of Nevada, Office of Governor Brian Sandoval

Credit: Silver State Health Insurance Exchange

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State of Nevada, Office of Governor Brian Sandoval

Medicaid

  • Caseload growth
  • FMAP impact
  • Spending trends
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In December 2012, Governor Sandoval opted in to the Affordable Care Act’s Medicaid expansion in order to provide Medicaid eligibility to childless adults with incomes below 138% of the federal poverty level. These clients became eligible for coverage in January 2014 and by July 2018, 152,959 childless adults were enrolled in Medicaid. Additionally, states had the option to expand Medicaid coverage to non-elderly, non-pregnant adults at or below 133% of federal poverty level. This allowed for “newly eligible” adults to apply. This population includes those who would not have been eligible for Medicaid in the state as of December 1, 2009 or were eligible under a waiver but not enrolled because of limits or caps on waiver enrollment.

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State of Nevada, Office of Governor Brian Sandoval

Credit: Nevada Department of Health and Human Services

Medicaid Expansion

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Nevada Medicaid Newly Eligible Adults Enrolled

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State of Nevada, Office of Governor Brian Sandoval

Credit: Office of Analytics, Department of Health and Human Services 37,231 164,423 195,373 207,448 213,331 50,000 100,000 150,000 200,000 250,000 FY14 FY15 FY16 FY17 FY18

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Nevada Medicaid Caseloads by Category

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State of Nevada, Office of Governor Brian Sandoval

Credit: Office of Analytics, Department of Health and Human Services

Month Moms and Kids Aged, Blind, and Disabled Newly Elig. Parent- Caretakers Childless Adults Other Total

January 2014 242,421 72,139 10,218 18,196 16,511 359,485 January 2015 282,527 79,617 48,138 118,096 23,734 552,112 January 2016 300,374 85,728 59,057 140,180 28,819 614,158 January 2017 309,403 92,287 61,645 148,278 30,415 642,028 January 2018 315,037 96,301 61,694 153,100 31,488 657,620 Projection January 2019 319,178 98,915 61,036 153,595 32,065 664,789 Projection January 2020 324,932 101,534 61,179 155,860 32,709 676,214 Projection January 2021 329,498 103,190 61,399 157,903 33,228 685,218

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Nevada Medicaid Caseloads by Category

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State of Nevada, Office of Governor Brian Sandoval

Credit: Office of Analytics, Department of Health and Human Services

100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 Moms and Kids Aged, Blind, and Disabled Newly Elig. Parent-Caretakers Childless Adults Other Moms and Kids Proj. Aged, Blind, and Disabled Proj. Newly Elig. Parent-Caretakers Proj. Childless Adults Proj. Other Proj.

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Total Medicaid Recipients

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State of Nevada, Office of Governor Brian Sandoval

Credit: Office of Analytics, Department of Health and Human Services

231,923 272,271 289,940 299,548 374,020 558,713 608,237 637,796 654,943 660,745 671,436 681,537 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 YTD FY20 Projection FY21 Projection

Number of Clients

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Nevada Medicaid Spending

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State of Nevada, Office of Governor Brian Sandoval

Credit: Data Warehouse of Nevada

$0 $500,000,000 $1,000,000,000 $1,500,000,000 $2,000,000,000 $2,500,000,000 $3,000,000,000 $3,500,000,000 $4,000,000,000 2012 2013 2014 2015 2016 2017 2018 Appropriations Fed Title XIX County Reimbursement Transfer from LTC Provider Tax Total Receipts/Funding YTD Actual

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Nevada Medicaid Spending

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State of Nevada, Office of Governor Brian Sandoval

Credit: Data Warehouse of Nevada

Year Appropriations Fed Title XIX County Reimbursement Transfer from LTC Provider Tax Total Receipts/Funding YTD Actual

2012 $506,794,541 $922,279,518 $30,609,977 $26,089,008 $1,638,664,986 2013 $515,970,808 $1,042,453,602 $27,747,281 $27,938,728 $1,740,345,035 2014 $521,139,479 $1,359,493,438 $25,922,441 $28,542,017 $2,027,481,859 2015 $564,081,027 $2,235,589,104 $25,167,479 $29,699,861 $2,975,550,583 2016 $530,882,511 $2,455,519,473 $25,677,771 $30,728,188 $3,226,886,022 2017 $599,663,914 $2,695,176,267 $27,811,510 $32,524,316 $3,554,479,256 2018 $671,703,899 $2,858,632,361 $21,263,285 $34,787,890 $3,771,619,863

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State of Nevada, Office of Governor Brian Sandoval

FPL Household Size 1 Household Size 4 22% $2,671 $5,522 26% $3,156 $6,526 100% $12,140 $25,100 122% $14,811 $30,622 133% $16,146 $33,383 138% $16,753 $34,638 165% $20,031 $41,415 200% $24,280 $50,200 205% $24,887 $51,455 2018 Federal Poverty Guidelines

Credit: Office of Analytics, Department of Health and Human Services

Medicaid Eligibility and FMAP

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Federal Medical Assistance Percentages (FMAP)

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State of Nevada, Office of Governor Brian Sandoval

Credit: Office of Analytics, Department of Health and Human Services

State Fiscal Year FMAP Enhanced (CHIP) FMAP ACA Enhanced (CHIP) FMAP New Eligibles FMAP

FY13 58.86% 71.20% FY14 62.26% 73.58% 100.00% FY15 64.04% 74.83% 100.00% FY16 64.79% 75.35% 92.60% 100.00% FY17 64.74% 75.32% 98.32% 97.50% FY18 65.48% 75.84% 98.84% 94.50% FY19 65.09% 75.57% 98.57% 93.50% Projection FY20 64.65% 75.26% 89.64% 91.50% Projection FY21 64.44% 75.11% 77.98% 90.00%

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State of Nevada, Office of Governor Brian Sandoval

Credit: Division of Health Care Financing and Policy

Hospitals – Main Total

$475,705,862.00 $396,349,732.01 $536,080,058.99 $581,616,616.47 $610,923,935.92 $581,501,010.02 $0 $100,000,000 $200,000,000 $300,000,000 $400,000,000 $500,000,000 $600,000,000 $700,000,000 SFY13 SFY14 SFY15 SFY16 SFY17 SFY18

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State of Nevada, Office of Governor Brian Sandoval

Credit: Division of Health Care Financing and Policy

Hospital Inpatient – PT011 Total

$420,507,397.39 $338,986,757.33 $459,123,285.75 $501,230,712.92 $521,501,426.39 $485,089,620.51 $0 $100,000,000 $200,000,000 $300,000,000 $400,000,000 $500,000,000 $600,000,000 SFY13 SFY14 SFY15 SFY16 SFY17 SFY18

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State of Nevada, Office of Governor Brian Sandoval

Credit: Division of Health Care Financing and Policy

Critical Access Hospital Inpatient – PT075 Total

$7,598,171.75 $9,189,181.09 $12,462,759.51 $13,890,858.62 $19,258,146.71 $22,631,093.87 $0 $5,000,000 $10,000,000 $15,000,000 $20,000,000 $25,000,000 SFY13 SFY14 SFY15 SFY16 SFY17 SFY18

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State of Nevada, Office of Governor Brian Sandoval

Credit: Division of Health Care Financing and Policy

Psychiatric Hospital Inpatient – PT013 Total

$8,255,213.07 $9,665,869.52 $12,694,984.96 $10,319,190.16 $8,652,188.76 $8,997,722.72 $0 $2,000,000 $4,000,000 $6,000,000 $8,000,000 $10,000,000 $12,000,000 $14,000,000 SFY13 SFY14 SFY15 SFY16 SFY17 SFY18

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$173 $199 $240 $358 $398 $462 $517 $0 $100 $200 $300 $400 $500 $600 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018

$ Millions (Total Computable)

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State of Nevada, Office of Governor Brian Sandoval

Credit: Division of Health Care Financing and Policy

Medicaid Behavioral Health Expenditures FY 12 – FY 18

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State of Nevada, Office of Governor Brian Sandoval

Credit: Division of Health Care Financing and Policy

Medicaid Behavioral Health Net Payment Expenditures FY 18

PT 11 Hospital, Inpatient (MH Revenue Codes) $37,735,342.00 PT 13 Psych Inpatient $8,408,244.59 PT 14 MH Outpatient $210,798,020.89 PT 17 Special Clinics $19,313,766.84 PT 26 Psychologist $3,490,850.79 PT 63 Residential Treatment Centers $33,596,063.10 PT 82 MH Rehab Services/ Non-Residential $3,737,335.11 PT 62 - MCO Cap Payments (Calculated) $200,269,041.90 Total $517,348,665.22

  • 1. Medicaid FFS Expenditures only, except for PT 62.
  • 2. PT 11 expenditures reflect selected BH/MH revenue codes. The fiscal measure is Allowed Amount, the amount of submitted

charges eligible for payment for all claims. This measure is used for reporting expenditures at the revenue and procedure code level.

  • 3. The fiscal measure for PTs 13, 14, 17, 26, 63 and 82 is Medicaid Net Payment, the net amount paid for all claims after all

pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.

  • 4. The expenditures for PT 62, MCO Capitation Payments, are based on a Milliman determination of the percentage of cap

payments dedicated to BH/MH care.

  • 5. Fiscal Year 2018 expenditures and patients as of August 17, 2018. FY 2018 ended on June 30, 2018, and in-state providers

have six months to submit claims.