Nevada scratches one idea off my "If I Ran the Zoo" list. 49 more states to go...

Last month I wrote up a list of 20 fixes/improvements to the ACA, many of which wouldn't cost taxpayers a dime. One fo them was...

12. LEGALLY TIE MEDICARE ADVANTAGE/MANAGED MEDICAID CONTRACTS TO EXCHANGE PARTICIPATION.

Andrew Sprung, Michael Hiltzik and I have all written about this before. I have no idea whether it's even legally feasible/practical or not, but if so, it makes a lot of sense to me: Remember, many of the same carriers whning about losing hundreds of millions of dollars on the individual market are simultaneously making billions of dollars in profit off of their other divisions...which include fat federal and state contracts to manage Medicare and/or Medicaid plans. If they want to play in the managed care sandbox, make exchange participation a requirement as well. I'm not saying they should have to treat it as a loss leader--they'd still be able to raise their premiums at an actuarially responsible rate as appropriate--but they should have to at least participate.

Lo and behold, it turns out that the state of Nevada is actually doing something very close to this already (h/t Louise Norris):

Looking ahead to 2018: State’s approach to MCOs helps to ensure exchange participation

...The rate filing deadline for 2018 plans in Nevada is May 17, 2017. There are currently exchange plans available in Nevada from Health Plan of Nevada (UnitedHealthcare), Prominence, and Anthem Blue Cross Blue Shield (both HMO and PPO entities).

Silver Summit currently only offers Medicaid/CHIP (Check Up) plans in Nevada. They confirmed by phone that they will be filing plans for 2018, and anticipate having qualified health plans (QHPs) available for purchase when open enrollment begins in November.

Aetna Better Health, another Medicaid managed care organization in Nevada, is also expected to submit plans for 2018 QHPs in the Nevada exchange, under the Aetna Health Inc. name.

In other words, assuming these both go through and none of the 3 current exchange participants drop out, Nevada will go from 3 exchange carriers to 5 next year...a solid (and unusual of late) increase in competition and choice. Woo-hoo!

So, why did these two carriers which are previously only known for their managed Medicaid plans suddenly jumping into the ACA exchange pool?

The expected entry of Silver Summit and Aetna to the exchange is linked to the state’s process for approving Medicaid managed care contracts. Prior to 2017, Nevada required its Medicaid Managed Care vendors (MCOs) to offer at least one silver and one gold plan in the state’s exchange. In other words, access to Medicaid Managed Care business was not available for carriers that opted not to participate in the exchange. Anthem (AmeriGroup) and United (Health Plan of Nevada) both operated Medicaid Managed Care plans in Nevada prior to 2017, and offered plans in the exchange.

For 2017, the state decided to allow four Medicaid MCOs instead of just two. And while they eliminated the requirement that Medicaid MCOs also offer QHPs in the exchange, the Nevada Division of Insurance reports that during the process of selecting MCOs, the state added five additional points to the scores of insurers that indicated on their MCO proposal that they would also offer QHPs in the exchange (MCO contracts are awarded to the insurers that get the highest scores). The Division of Insurance confirmed in early May that they expect all four of the state’s MCOs (Anthem, United, Silver Summit, and Aetna) to file rates and plans for 2018 QHPs that will be sold in the exchange.

In March 2017, Anthem’s continued participation in the exchanges where they currently offer coverage — including Nevada — was in question. However, Nevada’s process of granting higher scores to MCO proposals from insurers that commit to the exchange likely meant that Anthem’s participation in Nevada’s exchange was more certain than in other states. And by late April, the insurance giant was leaning towards continuing to offer coverage in all of its current exchanges, contingent upon the Trump Administration making all required cost-sharing reduction payments to insurers.

In other words, Nevada already did have exactly the requirement I'm suggesting above in place for 3 years. They've since weakened that regulation, but it still amounts to almost the same thing: It's a direct contractual and financial incentive to private carriers to participate in the exchanges if they want to get some of that sweet, sweet MCO cash.

I'd still prefer making it contractually required, but I suppose this "extra credit if you do" thing might work as an alternative.

Now if the other 49 states would just do the same thing, we'd be getting somewhere...