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Overview

Nevada currently has three (3) medical managed care organizations (MCOs) and one dental benefit administrator (DBA).  Medical care in the managed care coverage areas is provided by the following MCOs:

 

Anthem Blue Cross Blue Shield – 183,461 members*

Health Plan of Nevada – 236,767 members*

SilverSummit Healthplan – 47,756 members*

All Medicaid recipients who live in urban Washoe County (Reno) or Clark County (greater Las Vegas area) who are not determined disabled by the Social Security Administration are mandated to enroll in an MCO.

*Membership statistics as of October 2019.

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Eligibility

The managed care program in Nevada allows voluntary enrollment for the following recipients (these categories of enrollees are not subject to mandatory lock-in enrollment provisions):

  • Native Americans, who are members of federally recognized tribes except when the MCO is the Indian Health Service, an Indian health program, or urban Indian program operated by a tribe or tribal organization under a contract, grant, cooperative agreement, or compact with the Indian Health Service.
  • Children younger than 19 years of age who are receiving services through a family-centered, community-based, coordinated care system that receives grant funds under Section 501(a)(1)(D) of Title V and is defined by the State in terms of either program participation or special health care needs (also known as children with special health care needs—CSHCN).
  • Family Medical Coverage (FMC) adults determined as seriously mentally ill (SMI). Newly eligible SMI adults are enrolled in an MCO if they reside within the managed care.
  • FMC children diagnosed as severely emotionally disturbed (SED).

In 2017, the Nevada Division of Health Care Financing and Policy (DHCFP) procured a dental prepaid ambulatory health plan (PAHP), LIBERTY Dental Plan to serve as the dental benefits administrator for Clark and Washoe counties, with coverage effective 1/1/2018.

Services not currently covered by Managed Care in Nevada include Hospice, Adult Day Health Care, Non-Emergency Transportation, Targeted Case Management, Home and Community-Based Waiver Services, Intermediate Care Facilities for Individuals with Intellectual Disabilities, Nursing Facility Stays more than 45 days, Orthodontia and Residential Treatment Center stays more than 30 days.  These services are covered by traditional Medicaid and paid on a fee-for-service basis.

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Coverage

Managed Care in Nevada covers most of the services that are in the Medicaid-approved State Plan, including:

  • Physician/Hospital Services
  • Pharmacy
  • Behavioral Health Services
  • Personal Care Services
  • Home Health
  • Therapy Services

MCOs in Nevada have the flexibility to offer additional services based on need and the plan selected.  

 

Data Considerations

HMS receives both FFS paid claims data and MCO encounter data on behalf of Nevada Medicaid.  The data set claim and encounter data for Nevada is complete.

It is important to note that The Nevada Department of Health and Human Services (DHHS), Division of Health Care Financing and Policy (DHCFP) implemented a new Medicaid Management Information Systems (MMIS) on February 1, 2019.  As a result, there are a couple of data considerations to keep in mind:

  1. Nevada supplied HMS with a 3-year refresh file of converted data as part of its MMIS conversion. This means that every claim and encounter with a DOS between 2/1/2016 and 1/31/2019 is captured across two distinct HMS systems; PCF and CCBD, which is why there are two data set slides for Nevada.  However, the newest CCDB data was loaded first so only unique records from PCF were loaded to eliminate the possibility for duplicated records.

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  2. HMS does not currently receive an encounter indicator for claims processed after the state’s MMIS conversion go-live date of 2/1/2019.  Therefore, the ability to distinguish between FFS claims and MCO encounter data will be difficult where the DOS is on or after 2/1/2019.

 

 

Sources

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